Individual at Manchester

Investigation into the circumstances surrounding
the death of a man in January 2009
following his release from HMP Manchester
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2009
This is the report of the investigation into the death of a man, from a drugs overdose,
within hours of his release from HMP Manchester on 28 January 2009. This
investigation has been carried out under the Ombudsman’s discretionary power to
consider deaths following release from custody.
I offer my sincere condolences to his family and partner for their loss.
The investigation was conducted by one of the Ombudsman’s investigators. The
investigator received excellent support from the Safer Custody team at Manchester.
I would like to thank the Governor and his staff for their co-operation with the
investigation.
Manchester Primary Care Trust (PCT) commissioned a clinical reviewer to undertake
a review of the clinical care the man received at Manchester. The man spent the
first four months of his time in custody at HMP Hewell and the clinical reviewer’s
review has also considered the clinical care provided to him there. I am grateful for
her thorough review.
The man had a history of intravenous drug use, and had sought treatment for this in
the community. Before he was remanded into custody, he was being prescribed the
heroin substitute, methadone. Whilst at Hewell, the man continued to address his
substance misuse, engaging with the prison’s substance misuse service. He was
offered further support on his transfer to Manchester but, at the time, felt he did not
need it.
The man also had a history of mental health problems, and was being prescribed
medication. Staff at both prisons struggled to gather information about his medical
history in the community, although this does not seem to have impacted on the care
he received. However, I have identified some shortcomings in the clinical care
provided at both prisons. In addition, the management of discharge processes at
Manchester has been examined. I make three recommendations in relation to
healthcare provision at Hewell, three regarding healthcare provision at Manchester,
and three concerning release arrangements from Manchester.
The transition from prison to the community is fraught with difficulties for many
prisoners and it is important that prisons do all they can to properly prepare those in
their care. That said, despite the warnings he had received and having apparently
been drug free for eight months, the man chose to return to drug use on the day he
was released.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman December 2009
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CONTENTS
Summary
The investigation process
HMP Manchester
Key events
Issues
Conclusion
Recommendations
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SUMMARY
The man who died was remanded into the custody of HMP Hewell on 8 May 2008,
charged with assault and affray. He told reception staff that he had a history of
substance misuse and was being prescribed methadone. The man also said he had
mental health problems and heard voices when he felt stressed. He said he was
receiving treatment from a doctor linked with a community drugs service in his local
area and had been prescribed anti-psychotic and anti-depressant medications. He
was assessed by a prison doctor who requested that further information about the
man’s medical history be sought from the community drugs service. (However, it
appears that no confirmation was ever received.) In the meantime, he prescribed
the two medications the man had named at the same dosage level he said he had
been prescribed previously. He also directed that the man undergo a 14 day
methadone detoxification. (This is when the individual is prescribed a decreasing
dose of methadone, until it is no longer necessary. The process is managed by
healthcare staff.)
Whilst at Hewell, the man engaged with the prison’s substance misuse team. He
said that he wanted support in prison and to remain drug free when he was released.
He told the substance misuse worker that he had overdosed once in the past. In
June 2008, the man completed a four week programme for prisoners with substance
misuse problems. During the programme, and in one to one sessions with his
substance misuse worker, the risks of returning to drug use on release were
explained to him. He was told that after a period of abstinence, drugs in the
community would be stronger than he was used to. He was warned that if he
returned to drug use on his release, he should use smaller amounts of drugs until his
body became accustomed. The man was also told that using drugs whilst taking
prescribed medication could be dangerous.
Staff on the wing where the man lived were concerned that the prescribed doses of
medication were too strong. They asked healthcare staff to reassess him, and his
medication was altered.
In early September 2008, the man was found guilty of his offences and sentenced to
15 months in prison. On 9 September, he was transferred to HMP Manchester
because Hewell was overcrowded. The man saw a nurse in reception but did not
undergo a full assessment. He told the nurse about his mental health problems and
the medication he was prescribed. He was assessed by a doctor and the same
medication was prescribed. He also saw a mental health nurse who told the man
that she would approach the community drugs service for further information about
the treatment he had received.
Following his transfer, the Hewell substance misuse service transferred the man’s
file to Manchester. He was allocated to a substance misuse worker at Manchester,
who visited him on 24 September. The man said that he did not currently need any
further support. The substance misuse worker told him that he could ask to see him
at any time and said that he would visit again before he was released. (In fact, due
to an administrative error, the substance misuse worker did not see the man before
his release.)
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During his time at Manchester, the mental health nurse continued to try to trace his
medical history from the community, with limited success. She referred the man to
the prison psychiatrist, who treated him during his time at Manchester and liaised
with the mental health nurse. However, the man’s case was not managed by the
mental health in-reach team and due to confusion, he did not undergo a full mental
health assessment.
The man was due to be released on 28 January 2009. He met with a principal
officer two days beforehand, who completed the discharge paperwork. No issues
were raised and the man was released from the prison at 2.00pm on 28 January. He
did not see a nurse before his discharge and was not provided with a supply of his
medication. The man was released on licence, to be supervised by probation. He
was returning to the flat he had lived in prior to coming to prison.
Several hours after his release, the man was found in an “intoxicated” state in his
local area. He quickly lapsed into unconsciousness and, despite efforts to
resuscitate him, died at 7.18pm. The post mortem concluded that he had died of a
heroin overdose.
This investigation has identified shortcomings in the (mental) health systems in place
at Hewell and Manchester, and in the discharge procedures at the latter. I make
nine recommendations in total.
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THE INVESTIGATION PROCESS
1. The Ombudsman’s office was notified of the death of the man on 29 January
2009. The investigation was allocated to an investigator on 5 February 2009.
The Investigator visited HMP Manchester on 12 February and met the Governor
and representatives from the Prison Officers’ Association and the Independent
Monitoring Board.
2. The investigator issued notices inviting staff and prisoners to contact her with any
information they felt might be relevant to the investigation. There was no
response to these notices. The investigator was provided with copies of the
prison records relating to the man’s time at Manchester, and those relating to the
period that he spent at HMP Hewell (formerly known as Blakenhurst), prior to his
transfer. She conducted interviews with staff at Manchester in April. Relevant
staff at Hewell were contacted by telephone.
3. Manchester PCT appointed a clinical reviewer to conduct a clinical review of the
care the man received at Manchester. Her review also considered the clinical
care provided at Hewell. Both the investigator and the clinical reviewer were
given copies of the man’s medical records. They conducted several joint
interviews with members of healthcare staff.
4. During the investigation, the investigator also made telephone contact with
representatives from his local Drug Action Team (DAT) and Drug Intervention
Programme (DIP), and the man’s probation officer in the community.
5. The investigator approached HM Coroner for sight of the post mortem and police
investigation report into the man’s death. The results of the post mortem are
outlined later. It has not been possible, however, to arrange a copy of the police
report in time for inclusion here. HM Coroner will be provided with this report to
assist him with the inquest.
6. A senior family liaison officer for the Ombudsman, contacted the man’s family and
partner to invite them to be involved in the investigation process. The man’s
partner said that she had visited the man at Manchester three days before his
release. He told her that he had stored a quantity of the medication he was being
prescribed in prison, and had taken six tablets that day. She said that, although
he appeared relaxed, he was unable to concentrate or sit still. His partner did not
tell staff about her concerns at the time. She wanted to know where he had got
the tablets from, and was concerned that he was not more closely supervised
when given his medication. She also had concerns about the mental health care
the man received.
7. The man’s partner said that when he did not arrive at the family home as
expected on 28 January, his family contacted the prison to check he had been
released. She said that the prison was unwilling to confirm this. The investigator
agreed to consider these concerns during the investigation. The man’s partner
was also unsure what had caused the man’s death. I hope that this report
provides the man’s family and partner with a better understanding of what
happened on 28 January, and during the preceding months.
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HMP MANCHESTER
8. HMP Manchester is a category A local prison serving the courts of the Greater
Manchester area. It holds up to 1,269 adult male prisoners on remand, convicted
and sentenced. The prison became part of the high security estate in April 2003.
However, as a local prison, it accommodates both category A and other category
prisoners.
9. The National Offender Management Service (NOMS) publishes quarterly
performance ratings of prisons in England and Wales, with each prison being
assessed across a number of set indicators. Over the three published quarters of
2008/09, Manchester’s performance has been deemed “exceptional”, the highest
possible rating.
10. HM Chief Inspector of Prisons, conducted an unannounced short follow-up
inspection of the prison in May 2007, following a full announced inspection in July
2004. A further full announced inspection took place in July 2009. All inspection
reports include a summary of the prison’s performance against the model of a
healthy prison. There are four criteria of a healthy prison: safety, respect,
purposeful activity and resettlement. The resettlement test requires that
“prisoners are prepared for their release into the community and helped to reduce
the likelihood of reoffending”.
11. The criteria used by the Inspectorate to assess the conditions in prisons and the
treatment of prisoners is set out in their ‘Expectations’ document. Section 8 of the
document details the criteria used to assess how the prison manages the
resettlement of its prisoners. Amongst others, the expectations in this area
include:
(cid:127) That the prison has an up to date resettlement strategy.
(cid:127) That prison staff work collaboratively with both statutory and non-
statutory agencies to achieve positive outcomes for prisoners.
(cid:127) That all prisoners have a written plan that specifies how their specific
resettlement needs will be met during and post custody.
(cid:127) That assessments and sentence plans are produced and reviewed
jointly with the prisoner and all staff or agencies directly involved with
the prisoner.
(cid:127) That there is a high level of integration between sentence planning
and other functions within the prison.
12. During the follow-up inspection in 2007, the Inspectorate reported that the
improvements noted in 2004 remained and that staff-prisoner relationships had
improved. The Inspectorate found that resettlement “remained a fairly good
story”, noting improvements in sentence planning for both long and short term
prisoners.
13. Each prison in England and Wales is also monitored by an Independent
Monitoring Board (IMB), the members of which are volunteers from the local
community. Members of the Board have full access to every part of the prison
and each prisoner held there. The IMB produce annual reports for each
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establishment, the latest available report for Manchester covering March 2007 to
February 2008.
14. The IMB reported that, in their view, Manchester was a “well-run prison”. It was
noted that the prison had retained its ‘High Performance’ status for a second
consecutive year. The IMB reported that the prison had established good links in
the community to assist prisoners’ resettlement.
HMP HEWELL
15. HMP Hewell was created in June 2008 by the amalgamation of three former
prisons on the site (HMPs Blakenhurst, Brockhill and Hewell Grange). The prison
mainly serves the courts of the West Midlands, Worcestershire and Warwickshire.
It can hold up to 1,431 category B, C and D prisoners.
16. Hewell has not yet been inspected by HM Inspector of Prisons. However,
Blakenhurst (where the man served some of his sentence) underwent a full
unannounced inspection in December 2005. Then, the Chief Inspector found the
prison to be “well-run and stable”. The prison was deemed to be performing
reasonably well against each of the four healthy prison tests.
CARATs
17. CARATs teams (Counselling, Assessment, Referral, Advice and Throughcare
service) are in place in each prison in England and Wales. The service provides
support and non-clinical treatment to prisoners with substance misuse needs.
CARATs offers a number of interventions for prisoners, including one to one
counselling and groupwork, and liaising with community services prior to release.
Short Duration Programme
18. The Short Duration Programme (SDP) is a structured short intervention for
prisoners with substance misuse problems. Participants attend 20 sessions over
a four week period. The programme is based on a cognitive behaviour and harm
minimisation approach. (Cognitive behaviour aims to help the individual change
the way they think, feel and behave. Harm minimisation acknowledges that
substance misuse will occur but provides individuals with information and
techniques that reduce the risks involved.)
19. Week 1 of the programme covers substance awareness, harm minimisation and
the treatment services available both inside and outside prison. Week 2 focuses
on harm minimisation and relapse prevention. Week 3 covers “high risk
situations”, coping with cravings and relationships. The final week reviews the
programme and focuses on the individual’s relapse prevention plan.
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KEY EVENTS
20. On 8 May 2008, the man appeared at a local magistrates’ court charged with
affray and common assault. He was remanded into the custody of HMP Hewell.
On arrival, the man underwent the first reception health screen with a nurse.
(The first reception health screen is carried out when a prisoner first arrives in
prison. It is designed to identify any immediate physical or mental health
concerns which require referral to a doctor or other specialist service.) The man
told the nurse that he was under the care of a doctor at Addaction (a substance
misuse service in his local area). He said that he had mental health problems
and was currently being prescribed anti-psychotic medication (risperidone) and
an anti-depressant (mirtazepine). The man said he heard voices when he felt
stressed.
21. During the first reception health screen, the man also said that he had used
heroin in the month prior to coming to prison. He said he was currently
prescribed 80mg of methadone a day. The man denied using cocaine, crack
cocaine and cannabis. However, he underwent a drugs test which suggested he
had recently used heroin, methadone, cocaine and cannabis. He denied using
any drugs intravenously. The man said he drank about 18 to 20 units of alcohol
every day. Following the health screen, the nurse recorded that the man should
be referred to for a mental health assessment and to CARATs. The nurse noted
that the man had a burn on his forearm, which had been dressed by a police
doctor. Dressings were reapplied by healthcare staff over the next two days.
22. The following day, 9 May, the man was assessed by a member of the mental
health team, who carried out the initial mental health screen. The man said he
heard “mumbling voices outside his head” and sometimes found it hard to
concentrate. He confirmed the medications he was currently being prescribed
and the doses. As a result of the screen, the man was referred to the prison
doctor for further assessment.
23. Later that day, the man was examined by a doctor who made a note of the
appointment in his medical record. The doctor noted that confirmation of the
man’s medication should be sought from his doctor in the community. In the
meantime, the man was prescribed risperidone and mirtazepine at the same
dosage level as he said he had been prescribed in the community. A fax
requesting the man’s “relevant medical history … or a summary of care” was sent
to Addaction that day. There is no indication that Hewell received any information
from Addaction in response. The doctor also recorded that the man should
undergo a methadone detoxification. (This is when an individual dependent on
opiate substances or methadone is prescribed a decreasing dose of methadone
over a set period of time, until they no longer need to take any. The detoxification
process is carefully managed by healthcare staff.) Despite the man’s high intake
of alcohol prior to his remand, the doctor did not suggest that he undergo an
alcohol detoxification, and no direction was made that the man be monitored for
signs of withdrawal.
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24. On 19 May, the man was assessed by a CARATs worker at the prison. The man
told the worker that he was currently receiving treatment for his drug use from his
local DIP and Addaction. He agreed to work with CARATs during his time at
Hewell. The CARATs worker recorded that the man needed structured support,
including information on how to use substances safely and avoid overdosing.
25. The man and the CARATs worker drew up a care plan setting out the man’s
objectives and who was responsible for helping him achieve them. The man said
that, once his methadone detoxification was complete, he wanted support to help
prevent him returning to drug use. He said that he would like support in the
community when he was released from prison. Finally, the man wanted the
prison mental health team to help him with his mental health problems. The man
and the CARATs worker agreed that the care plan would be reviewed over the
course of his time in prison.
26. On 27 May, the man underwent a further mental health assessment, following the
CARATs worker’s referral. The man said he had trouble sleeping due to hearing
voices. He thought the voices were stopping him from mixing with other
prisoners. The nurse completing the assessment recorded that the man would
benefit from an increased dose of risperidone at night time. As a result, the man
was referred to the doctor and later that day, the doctor increased the risperidone
dose.
27. The man met his CARATs worker again on 28 May and the Comprehensive
Substance Misuse Assessment (CSMA) was completed. The CSMA provides a
more detailed account of the individual’s substance use, and helps to identify their
support needs. The CARATs worker recorded that the man had now completed
his methadone detoxification. He said that he would like to attend the Short
Duration Programme (SDP). The CARATs worker recorded that the man would
need a one to one session on the risks of overdose and tolerance levels as he
had overdosed in the past. Following the meeting, the CARATs worker recorded
that she had referred the man to the SDP and that he would begin the course in
June. She also sent a fax referral to his local DIP advising them that the man
would need their support on release from prison.
28. During the man’s first few weeks at Hewell, staff on the wing where he lived
appeared to have few concerns about him. Entries in his prison file indicate that
they found him to be “polite and respectful” and thought he was settling in well.
However, on 11 June, an officer recorded that the man “seemed in a confused
state” and that he should be “monitored closely”. Ten days later, the officer made
a second entry noting that the man appeared to be a “heavily medicated
individual” who “doesn’t seem to know much about what’s going on”. Over the
following weeks, staff recorded that whilst the man caused no problems on the
wing, he seemed to be “in his own world”. They wrote that he tended not to mix
with other prisoners on the wing.
29. The man began the SDP on 18 June. The Drug Treatment Progress Report,
written by the man’s case worker, detailed the sessions he completed and the
progress he made on the course. The man attended 19 of the 20 sessions and
was praised for his “undoubted motivation”. Of particular relevance is that
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session 16 of the programme, which he attended, focused on overdose
management, including “being aware of reduced tolerance levels, different
strengths/purity of substances, not mixing drugs and not using alone”.
30. On 17 July, the man attended a post course review meeting with his CARATs
worker, the SDP facilitator and his probation officer. The man said he had
identified high risk situations and triggers for his drug use. He said that, in the
future, he would seek support from the DIP team to avoid relapsing. The man’s
probation officer warned him of the dangers of using illicit drugs while taking
prescribed medication, telling him that he risked overdosing if he did so.
31. Another wing officer made an entry in the man’s prison file on 25 July, describing
him as “zombie-like” and living a “worryingly lonesome existence”. A further entry
that day recorded that, in the light of staff comments, the man should be
assessed by the mental health team. On 29 July, an entry was made in the
man’s medical record stating that he should be reviewed by both the mental
health in-reach team and the doctor. However, the man did not go to an
appointment with the doctor two days later. There is no evidence to suggest that
the man was further assessed by either a doctor or the mental health in-reach
team whilst at Hewell.
32. The man appeared at a local crown court in September. He was found guilty of
his offences and sentenced to 15 months and 14 days imprisonment. Because of
the length of time on remand, the man was due to be released on 28 January
2009. Two days later, the CARATs worker sent a fax to the local DIP informing
them of the man’s sentence and expected release date. The following day, she
faxed further information about the man to the DIP, reiterating that he would
“require support upon release”.
33. On 9 September, eight days after his court appearance, the man was transferred
from Hewell to HMP Manchester because Hewell was overcrowded. He saw a
nurse in reception. The nurse was interviewed as part of this investigation but
could not recall having seen the man in reception that day. The nurse explained
that transferred prisoners did not always undergo a full reception health screen.
Instead, the member of healthcare staff would talk to the prisoner to identify any
immediate needs. If necessary, referrals could be made to the doctor or other
service. The nurse recorded that the man was currently being prescribed
risperidone and mirtazepine. She wrote “same prescribed here, referred to
[mental health in-reach team]”. The nurse explained that she would not prescribe
the medication and that the man would have seen a doctor in reception. There is
no information in his medical record to indicate which doctor he saw, or who
confirmed the prescription.
34. Later that evening, the man was assessed by a psychiatric nurse working with the
mental health in-reach team. She noted that he had no connections with
Manchester, and that his family and partner lived in a different area. The
psychiatric nurse recorded that the man was known to mental health services in
his local area. She wrote that she would “obtain further information from them
tomorrow and to ascertain needs”.
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35. The psychiatric nurse was also interviewed during the investigation. She said
that the reception nurse who initially assessed the man had asked her to assess
him because of his mental health history. The psychiatric nurse described the
man as being “quite nervous” and possibly did not understand why he had been
transferred to Manchester. The man told her that he was receiving treatment
from a doctor linked with Addaction. The psychiatric nurse said that she would
seek further information about him. She completed only a small part of the
assessment and did not think she needed to complete the entire document as
she did not intend to take him on to her caseload thinking he did not meet the
criteria.
36. The man was located on H wing, where he underwent the first night assessment
and induction with an officer. The man was described as being quiet and
withdrawn, but polite and co-operative. He appeared to be “very nervous” about
being at Manchester. However, the following day he underwent the second day
interview, intended to provide a further opportunity to raise concerns and said that
he had no concerns about being at Manchester.
37. On 16 September, the CARATs worker at Hewell completed a transfer plan and
sent the man’s CARATs file to Manchester. She also faxed his local DIP to let
them know that the man had been transferred. The transfer plan detailed the
man’s main issues, and his “key achievements” to date. It also outlined his
outstanding goals. They included being referred to the Blood Borne Virus (BBV)
nurse and receiving Hepatitis B screening, liaising with the DIP team and
undertaking an Enhanced Thinking Skills (ETS) course. (The ETS course is a
short programme addressing thinking and behaviour associated with offending. It
is available to all prisoners, not only those with substance misuse issues.) The
CARATs worker also noted that the man would need a one to one session on
overdose and tolerance. The investigator spoke to the CARATs worker by
telephone. She said that it is common practice at Hewell to offer a final session
on the risks of overdose and tolerance levels shortly before prisoners are
released. This would have been offered to the man although he had already
received the information via one to one sessions and the SDP.
38. On receiving the man’s CARATs file from Hewell, the Manchester CARATs team
allocated him to a caseworker. The investigator interviewed the man’s
caseworker as part of the investigation. He explained that the role of the
CARATs worker is to “work in unison” with the individual to address their
substance use. He said that the level of contact with prisoners on his caseload
differed according to their specific needs and the length of their sentence. The
caseworker was asked how many prisoners he had on his caseload in September
2008, when the man arrived at Manchester. He said that, at that time, he had
around 40 prisoners on his caseload. More recently, his caseload had reduced to
about 30.
39. The caseworker explained that, on receiving the man’s file, he checked to see
what work had already been done with him and what his outstanding needs were.
He met the man for the first time on 24 September and recorded the meeting in
his file. He noted that the man said he was “fine at the moment and had done all
his courses”. The caseworker told the man to contact him if he needed any
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support. In interview, the officer said he told the man his file would remain open
with CARATs and that he would see him again before his release. In fact, the
caseworker did not see the man before he was released in January 2009.
40. My investigator asked the caseworker about the outstanding actions the CARATs
worker at Hewell had outlined on the man’s transfer plan. He explained that the
referral to the BBV nurse and for Hepatitis B screening would normally take place
about six weeks before a prisoner’s release. He also said that the man was not
suitable for referral to the ETS course because he was due for release in January
and there was a long waiting list for the ETS course. The caseworker said that he
would normally telephone the relevant DIP team prior to a prisoner’s release to
make an appointment. The caseworker did not refer the man to the BBV nurse or
for Hepatitis B screening. In addition, he did not telephone the local DIP to
remind them that the man was being released and make an appointment for him.
(It would, however, have been the man’s decision whether or not to attend such
an appointment.)
41. My investigator also interviewed the CARATs manager. He confirmed that he
expected his staff to arrange to see prisoners five to six weeks before their
release date. At this stage, the CARATs worker should make the prisoner an
appointment with the relevant community drugs service. He said that he would
also expect his staff to reiterate messages about the risks of using drugs on
release.
42. In interview, the caseworker explained that individual CARATs workers have their
own systems for recording the expected release dates of the prisoners they work
with. Although he recorded the man’s release date in his files, he did not realise
that the date was approaching. As a result, he did not see the man prior to his
release nor make the usual pre-release arrangements for him.
43. During the course of this investigation, the investigator spoke to the Head of
Offender Management at Manchester. He explained that the man would have
been subject to sentence management and planning throughout his sentence.
(Sentence planning ensures that individual prisoners receive the right
interventions whilst in prison and that community ties, which will aid their
resettlement, are supported.) The Head of Offender Management said that the
man would have been invited to sentence planning meetings every two months.
He also said that the man’s probation officer would have been invited to
contribute. Unfortunately, Manchester could not locate any sentence planning
documents relating to the man. The man’s probation officer in the community,
was spoken to by telephone and said that he had not visited the man at
Manchester. He explained that this was standard practice given the relatively low
risk nature of the man’s offending behaviour and the distance from the area he
works in to Manchester. He confirmed that he had not received any sentence
planning information from Manchester.
44. Following her meeting with the man on 9 September, the psychiatric nurse
contacted Addaction in his local area on 26 September to gather more
information about his mental health needs. Addaction told her that they did not
know the man. The psychiatric nurse wrote that she would make further
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enquiries to establish who had been treating him in the community. Three days
later, she spoke to the man on the wing and told him that she was unable to
identify which community service had been treating him. The man repeated that
he was under the care of a doctor working with Addaction.
45. The psychiatric nurse recorded that the man seemed low in mood because of the
distance from his family and partner. He told her that he hoped to be transferred
to a prison closer to them. The nurse recorded that she would refer the man to a
the prison’s associate psychiatrist for assessment.
46. On 6 October, the associate psychiatrist assessed the man. He noted that limited
information on the man’s previous medical history was available. He thought that
the man might be suffering with drug induced psychosis, although his symptoms
also suggested schizophrenia. The associate psychiatrist recorded that the man
was experiencing some side effects from the medication he was taking. He
prescribed procyclidine to combat the side effects, and agreed to continue the
prescription for risperidone and mirtazepine. He arranged to assess the man
again in four weeks.
47. In October, the man began attending education classes at the prison. The
investigator spoke to his tutor. She said that the man had gone to classes every
week day for three hours each day. She described him as quiet at first and so
she had spent time talking to him. Over time, the tutor said that the man began to
interact more with other prisoners in the class. He did well in his computing
classes and gained a number of certificates as a result.
48. The man was assessed by a locum psychiatrist, on 3 November. The locum
psychiatrist recorded that the man reported a “slight improvement” since his last
appointment. He told the locum that he was hearing the voices less frequently
and that they were more muffled. The locum recorded that the man had no
thoughts of harming himself or anyone else, but that his mood was slightly low
because his family were not able to visit. The locum directed that the man should
be reviewed in six weeks.
49. Over the next few weeks, the psychiatric nurse continued to try to identify the
community service which had initially prescribed the man’s medication. She
recorded that she had contacted the Community Drugs Team (CDT) in his local
area, also known as Inclusion. They confirmed that the doctor the man had
named worked with them. Unfortunately, the doctor could provide very little
information about the man and suggested that the psychiatric nurse contact the
man’s community doctor. She did so, and asked the surgery to fax any
information they held about the man to her. The psychiatric nurse received a
response from the surgery on 10 December. The doctors there had not treated
the man for any mental health problems and had not had any contact with him
since 2007. The psychiatric nurse recorded that she would visit the man on the
wing the following week, prior to his discharge from prison, in case anyone
needed to be contacted on his behalf.
14
50. In interview, the psychiatric nurse told my investigator that, although she was
going to some lengths to track down his medical history, the man was still not on
the in-reach team caseload. She said that his mental health needs were being
addressed by the associate psychiatrist and she did not feel there would be any
benefit from a referral to the in-reach team. The psychiatric nurse said that she
did, however, visit the man on the wing prior to his release. She asked him if
there was anything he would like her to do for him. He replied that there was not,
and that he planned to return to his local area on his release.
51. On 17 December, the associate psychiatrist assessed the man once more. He
recorded that the man was “feeling well” and, whilst he was experiencing less
severe side effects from his medication, he was still having some problems. The
psychiatrist increased the procyclidine dose. He recorded that the man was
expecting to be released on 28 January, and should be reviewed by the
psychiatric nurse in four weeks time, prior to his release. The psychiatrist was
under the impression that the man had in fact been taken onto the in-reach team
caseload.
52. The man’s tutor told the investigator that he attended his last IT session on 12
January. She talked to him about his release and he said that he was looking
forward to going home. The man told his tutor that he intended to take drugs on
his release. The tutor did not pass on the man’s comments to other staff, or to
the CARATs team, but said that she tried to encourage him to reconsider.
53. The man did not attend a scheduled appointment with the associate psychiatrist
on 14 January and no reason is recorded. The psychiatrist noted that the man
should attend a further appointment in three weeks time. (It appears that he had
not realised that the man was due for release in two weeks time.) There is no
record of any further appointments with healthcare staff prior to his release.
54. My investigator spoke to the prison’s Head of Healthcare. She said that all
prisoners should be assessed by a nurse about a week before their release. A
pre-discharge appointment was scheduled for 26 January, but the man did not
attend. The reason for his non-attendance is not recorded, and there is no
indication that any further action was taken to.
55. The man’s partner came to visit him on 26 January. She told the investigator and
family liaison officer that the man was unable to sit still or concentrate during her
visit. The man said that he had stored some of his prescribed medication and
had taken six tablets that day.
56. The Head of Healthcare was asked about how medication was distributed. She
explained that the man’s medication was ‘not in possession’. All medications
prescribed at Manchester undergo a risk assessment. Those considered low risk
may be held ‘in possession’, when the individual is given enough medication to
last a specified period of time. They keep the medication in their cell and are
responsible for taking the correct dose. Some medication is assessed as high
risk. It might be dangerous if wrongly taken, or might be particularly likely to be
traded or result in bullying between prisoners. This medication is distributed by
healthcare staff to prisoners on a dose by dose basis and is called ‘not in
15
possession’. The Head of Healthcare said that prisoners given a dose of ‘not in
possession’ medication must take it in front of healthcare staff. She said that staff
carry out a visual check to ensure that it was swallowed. In her opinion, it is
difficult for prisoners to hide medication, but she accepted that this can occur.
57. The investigator asked the associate psychiatrist what symptoms the man might
have experienced as a result of taking a higher than prescribed dose of his
medication. He said that the medications, if taken in excess, would have had the
opposite effect to that his partner described and that he would have appeared
lethargic. The psychiatrist was unable to say what might have caused the
symptoms the man’s partner described.
58. Prison Service Order (PSO) 6400 Discharge, advises that a discharge board be
held no more than two weeks before the prisoner’s release, to ensure that all
resettlement work has been completed. Relevant personnel from across the
prison and from the wider community may be invited to attend or submit a written
contribution. A principle officer (PO) completed the discharge board with the man
on 26 January. No other staff attended and no written contributions were made.
The principal officer was interviewed as part of this investigation and explained
that the board is normally held two days prior to release. She said it is the job of
a PO to hold the board, and that the POs on duty receive a list of boards to be
held each day. The principle officer explained that the discharge board serves
two main functions. The first is to check that the correct prisoner is being
released and that they have no further offences which might require the prison to
hold them in custody. She also explained that the board serves a “decency”
function, which is an opportunity to identify any problems the prisoner has prior to
release.
59. During the course of the board, a form must be completed which sets out 18
questions. The purpose of the form is to record that the questions have been
asked or the information checked. The prisoner’s responses or any action taken
as a result of the board are not recorded. Some questions relate to checking the
identity of the prisoner, others cover whether the individual has accommodation to
go to on release, or whether they have had contact with CARATs during their
sentence.
60. The principle officer said that the board is usually held in the POs’ office, with
other staff coming in and out of the room. She thought that the lack of privacy
might inhibit some prisoners from sharing any anxieties. She also explained that
the PO holding the board would not necessarily know, or need to know, the
prisoner due to be released. The principle officer did not know the man prior to
the discharge board. She asked him if he had accommodation arranged for his
release, and recorded that he did. She noted that he did not have any education,
training or employment arranged. The PO also asked the man if he had had any
contact with CARATs. She explained that if the prisoner said they had, she would
normally ask them if CARATs had made any arrangements for their release. If
the prisoner said that CARATs had not made any necessary arrangements for
them, she would contact the team to remind them.
16
61. The discharge form requires the PO to sign their initials to indicate the question
has been asked, but there is no space to record the prisoner’s response or any
other details. It is not, therefore, known how the man responded to the questions.
The principle officer said that the PO who completed the board would make an
entry in the prisoner’s wing history sheet to that effect. She said that, depending
on the prisoner’s answers, she might sometimes make a more detailed entry to
indicate any actions she had taken. She thought that, if she had contacted
CARATs on the man’s behalf, she would have made such an entry. The principle
officer made one entry in the man’s wing history sheet, which records “discharge
board held … No issues”. The discharge board makes no reference to contact
with healthcare.
62. Prior to his release, healthcare staff prepared a discharge letter (dated 26
January) for the man to give to his doctor in the community. It outlined the
medication he was prescribed but provided no details of his contact with the
associate psychiatrist. The man would have been given his discharge letter in
reception at the point of release from the prison. The Head of Healthcare
explained that prisoners are expected to make appointments with their doctor
themselves after release. Prisoners are normally released with seven days’
supply of their medication. The Head of Healthcare said that staff were unable to
locate the man’s discharge prescription and she was not certain that he had been
released with any medication. (The clinical reviewer has concluded that the man
was not given any discharge medication. He last received his prescribed
medication on the evening of 27 January.)
63. On 28 January, the man was taken to reception to be released. The investigator
interviewed the senior officer (SO) in charge of reception that day. He explained
that prisoners arriving and being released from the prison are processed through
reception. When a prisoner is being released, the reception SO is responsible for
checking the information on the discharge form, to ensure that the correct person
is being released. According to PSO 6400, it is good practice to warn all
prisoners being released that their tolerance to drugs and alcohol will be
significantly reduced and that they will be at a higher risk of overdose or
intoxification. The senior officer explained that while reception staff do not
verbally warn every prisoner of these dangers, they are all offered a discharge
pack. The pack contains warnings about the risks of using drugs on release from
prison, specifically that tolerance might have reduced whilst in prison and drugs
available in the community might be stronger than any available in prison.
64. The man was one of nine prisoners released from Manchester on 28 January.
PSO 6400 advises that prisoners should normally be discharged as soon as
possible after breakfast. According to reception records, the man was discharged
at 2.00pm with £365.95 in cash and a travel warrant to take him to his local area.
(On release, prisoners are given a cash discharge grant of £46 to cover
immediate expenses. The man was issued with the discharge grant and £319.95
personal cash.)
65. According to the man’s licence, he was to report to his probation officer by
3.00pm on 28 January. However, the senior officer recalled that there had been
a delay releasing the man, which meant he would not arrive in his local area in
17
time to report. A member of reception staff contacted the man’s probation officer
and it was agreed that he could attend first thing the following morning. (This is
not recorded on the licence paperwork, or elsewhere in the man’s file.)
66. It appears that the man arrived in this local area sometime that afternoon, and
went to a pub. In the early evening, he was found in an “intoxicated” state near a
local police station. He became unconscious and an ambulance was called.
Despite resuscitation efforts, hospital staff pronounced that the man had died at
7.18pm.
67. The post mortem results revealed that the man had consumed heroin and
cocaine and the cause of death was identified as heroin poisoning. The
toxicology results indicated that the levels of mirtazepine and procyclidine (two of
the medications being prescribed to the man) were slightly higher than expected
from the prescribed doses. The toxicologist noted that this could, in theory, have
added slightly to the toxic effect of the heroin. Alternatively, the report suggested
that the raised levels could have been caused by changes that happen naturally
in the body after death.
18
ISSUES IDENTIFIED DURING THE INVESTIGATION
68. Manchester Primary Care Trust (PCT) commissioned a clinical reviewer to review
the clinical care the man received at Manchester. As the man spent the first part
of his sentence at Hewell, her review also considered the clinical care provided
there. The clinical reviewer’s review is thorough and makes 12
recommendations. I have included some in the discussion below, but commend
the entire review to both prisons and the relevant PCTs.
Clinical care at HMP Hewell
69. On his arrival at Hewell, the man told healthcare staff that he had a history of
substance misuse and was being prescribed methadone. He said that he had
mental health problems and had been prescribed anti-psychotic and anti-
depressant medication by a doctor in the community. Prior to coming to prison,
the man said he was also drinking 18-20 units of alcohol each day. He was
placed on a methadone detoxification programme at Hewell. However, no entries
were made in his medical record about his progress or how the detoxification was
managed. Furthermore, the man’s alcohol use was apparently not addressed.
The Head of Healthcare at Hewell should implement a nationally
recommended pathway for alcohol and drug detoxification programmes in
reception.
70. The man told staff at Hewell he had been prescribed medication in the community
by a doctor working with a local drugs service in his local area. During his time at
the prison, staff were not able to locate the doctor or confirm the prescriptions.
Nevertheless, and without the man undergoing a full mental health assessment or
being referred to a psychiatrist, he was prescribed anti-psychotic and anti-
depressant medications. The prison doctor increased the dose of the anti-
psychotic medication being prescribed and, despite wing staff concerns, there is
no evidence that the effect of this increase was monitored by healthcare staff.
The Head of Healthcare should urgently develop policies and procedures
for prescribing medication to prisoners where details of an existing
medication regime have not been confirmed.
The Head of Healthcare should review the procedures and criteria for
referring prisoners for assessment and monitoring by a psychiatrist.
Clinical care at HMP Manchester
71. The man was transferred to Manchester on 9 September 2008 and saw the nurse
in reception. However, he did not undergo the full First Reception Healthscreen,
or any modified version of this. The nurse explained that it was not normal
practice at Manchester for transferring prisoners to complete the full assessment
unless there was specific reason to do so. This is not in line with PSO 3050
Continuity of Healthcare for Prisoners which indicates that all transferring
prisoners should be screened by a nurse before spending their first night in the
19
prison. The local protocol in place at Manchester meant that the man was not
subject to a secondary healthscreen either.
The Head of Healthcare should ensure that all transferred prisoners are
subject to reception screening in line with PSO 3050 and undergo a
secondary healthscreen.
72. The man was referred to the mental health team because of his existing mental
health problems and the medication he was being prescribed. The psychiatric
nurse saw the man in reception and continued to have contact with him during his
stay at Manchester. She did not, however, admit him to the mental health in-
reach team’s caseload as she did not think he met the criteria. Manchester
Mental Health and Social Care Trust, which is responsible for the in-reach team,
require a risk assessment for all patients. The psychiatric nurse completed only a
small part of that assessment, thinking that she did not need to do more unless
the man was to be taken on by the team. However, the risk assessment
document contains a shortened one page section, which staff were unaware of.
The psychiatric nurse should have completed the one page assessment.
73. The psychiatric nurse continued to see the man on an advisory basis, and he was
also seen by the associate psychiatrist. However, it appears that the mental
health in-reach team did not discuss the man’s ongoing care, nor were any
management plans completed. The psychiatrist did not realise that the man was
not on the in-reach team’s caseload, causing some confusion.
Manchester Mental Health and Social Care Trust should:
(cid:127) address staff confusion about the completion of the required risk
assessment documents and management plans for patients in
their care, and
(cid:127) ensure that the mental health in-reach team understand and
follow the correct procedures for assessing prisoners for
acceptance onto their caseload.
74. Prior to his release on 28 January 2009, the man should have seen a member of
healthcare staff and received seven days supply of his prescribed medication.
The man’s medical record indicates that he did not go to his pre-discharge
appointment and was not seen by healthcare staff before leaving the prison. In
addition, he did not receive his discharge medication. It is not clear why.
The Head of Healthcare should carry out an audit of the discharge
medication process to ascertain its effectiveness, reliability and safety.
The man’s transfer to Manchester
75. The man spent the first four months of his time in prison at Hewell, in the West
Midlands. His family and partner, who has a hearing impairment, live in his local
area. In September 2008, with just over four months of his sentence left to serve,
the man was transferred to Manchester because Hewell was overcrowded. The
psychiatric nurse and a doctor both recorded that the man’s mood was low
because his family and partner were not often able to visit him there. The man
20
told the psychiatric nurse that contact with his partner was particularly difficult as
they could not speak on the telephone.
76. Current prison population pressures mean, inevitably, that some prisoners are
placed in prisons a long way from their sources of support. It is unfortunate that
the man’s transfer, in effect, cut him off from his family and partner. It is also
unfortunate that he was transferred towards the end of his sentence when links
with community agencies become so important to successful resettlement. That
said, I do not believe that the man’s transfer ultimately played a part in his death.
The man’s contact with CARATs
77. On his arrival at Hewell, the man told healthcare staff that he had a history of drug
use. While at the prison, he engaged with CARATs and completed the SDP. the
man’s CARATs worker, told my investigator that she also undertook one to one
sessions with him that reiterated the dangers of returning to drug use on release.
The man’s CARATs worker informed the man’s local DIP that the man would
need their support on his release from prison. The CARATs file was
comprehensively completed and sent to Manchester when the man was
transferred there in September 2008.
78. The man’s caseworker from the Manchester CARATs team visited him on 24
September, but he said that he had done the relevant courses and did not need
his support at the time. The man’s caseworker intended to see the man again
before his release but did not. He explained to my investigator that, at the time
the man arrived at Manchester, each CARATs worker was allocated about 40
prisoners. He said this made it difficult to work effectively with them all and he
had to prioritise those with the greatest needs. The CARATs manager, said that
since the man’s death, they had worked hard to reduce the number of cases
individual officers managed, and staff should ideally have a maximum of 25
prisoners each.
79. The CARATs manager and the man’s caseworker told my investigator that
individual members of staff developed their own systems for recording the
expected release dates of prisoners on their caseload. They confirmed, however,
that the CARATs administrator also circulated a weekly list of prisoners due for
release. I think it would be sensible for the CARATs team to develop a robust
and centralised system for identifying upcoming release dates.
The Governor should encourage the CARATs team to develop a centralised
system for identifying and reminding staff of prisoners’ release dates.
80. I conclude, however, that, during his prison sentence, the man received
appropriate information about the risks of returning to drug use. It is not possible
to say whether hearing that message again some five to six weeks prior to his
release would have dissuaded the man from using drugs on 28 January.
However, I believe it unlikely.
21
Discharge procedures
81. Because of the circumstances of the man’s death, this investigation has focused
on the discharge processes in place at Manchester. PSO 2300 provides
instructions on how the resettlement of prisoners should be managed. It
emphasises the importance of multi-agency working. Although the PSO largely
refers to engaging agencies outside the prison, clearly it is important that the
different disciplines within the prison work well together too. Interviews with staff
from a range of disciplines suggest that the process is disjointed with the different
disciplines and agencies working in isolation to prepare prisoners for release. As
identified above, the man left Manchester without having been assessed by
healthcare, without his discharge medication and without having a pre-release
meeting with CARATs.
82. The Governor of Manchester, told the investigator he was considering
establishing a pre-release centre for prisoners with substance misuse issues, with
input from a range of disciplines. The purpose of the centre would, in part, be to
make sure that prisoners are fully aware of the risks of returning to drug use on
their release. The Governor explained however, that the Integrated Drug
Treatment Service, due to be introduced at Manchester in October 2009 was
expected to have an impact on the discharge and resettlement of substance
misusing prisoners. In light of the man’s experience, and the importance of
properly preparing prisoners for release, the Governor will wish to give some
consideration to this area.
The Governor should revise the current discharge procedures to ensure a
cross-disciplinary approach is adopted.
83. The principle officer who carried out the discharge board explained that discharge
boards were normally held in the principal officers’ office, with staff coming in and
out, and consequently, there was a lack of privacy. She thought this might inhibit
some prisoners from raising issues or anxieties.
The Governor should allocate a suitably private room for holding discharge
boards.
The family’s concerns
84. Having had sight of the draft version of this report, the man’s family remained
concerned that staff at Manchester had not been able to confirm whether and at
what time the man was released. Manchester responded to the draft report,
explaining that, for security purposes, the prison cannot give out such information
to members of the public who telephone the prison given the difficulties of
establishing the caller’s identity.
22
CONCLUSION
85. The man arrived in prison with a history of serious substance misuse. He had
sought treatment in the community and, whilst at Hewell, engaged with the
substance misuse service. He appeared to work hard to tackle his substance
misuse problems, undertaking the SDP and a methadone detoxification. It would
seem that he remained drug free during his time at both Hewell and Manchester.
However, hours after his release from Manchester, the man died from a heroin
overdose.
86. The man also had mental health problems and received interventions from the
healthcare and mental health teams at both prisons. This investigation has,
however, identified omissions in the treatment he received. Failings in the
discharge planning at Manchester have also been highlighted and
recommendations made.
87. This investigation highlights the very difficult transition from prison to freedom that
prisoners face. It also illustrates the onus on discharging prisons to do all they
can to properly prepare prisoners. That said, ultimately, it must be recognised
that it was the man’s choice to return to drug use on the day he was released.
23
RECOMMENDATIONS
To the Head of Healthcare at HMP Hewell:
1. The Head of Healthcare at Hewell should implement a nationally recommended
pathway for alcohol and drug detoxification programmes in reception.
This recommendation has been accepted. A piece of work has been agreed to
achieve this. The target date for completion is April 2010.
2. The Head of Healthcare should urgently develop policies and procedures for
prescribing medication to prisoners where details of an existing medication regime
have not been confirmed.
This recommendation has been accepted. The Prison Health Drugs and
Therapeutics committee will review and action and a protocol will be developed
by January 2010.
3. The Head of Healthcare should review the procedures and criteria for referring
prisoners for assessment and monitoring by a psychiatrist.
This recommendation has been accepted. An improved referral and allocation
process has been put in place. The Prison Health Directorate is also implementing
a new mental health strategy for Worcestershire prisons, involving a review of
access to mental health services. The new regional TAG referral process will be
implemented.
To the Head of Healthcare at HMP Manchester:
4. The Head of Healthcare should ensure that all transferred prisoners are subject to
reception screening in line with PSO 3050 and undergo a secondary
healthscreen.
This recommendation has been accepted. The Director of Healthcare will ensure
that all prisoners who transfer to HMP Manchester will have a secondary
healthscreen.
5. The Head of Healthcare should carry out an audit of the discharge medication
process to ascertain its effectiveness, reliability and safety.
This recommendation has been accepted and work will be completed by April
2010.
To Manchester Mental Health and Social Care Trust:
6. Manchester Mental Health and Social Care Trust should:
(cid:127) address staff confusion about the completion of the required risk
assessment documents and management plans for patients in their
care, and
24
(cid:127) ensure that the mental health in-reach team understand and follow the
correct procedures for assessing prisoners for acceptance onto their
caseload.
This recommendation has been accepted. The Mental Health In-Reach Team
leader will facilitate refresher training regarding the risk assessment process. An
audit will be completed regarding the quality of care plans and any findings acted
upon. The procedures for assessing prisoners for acceptance onto the Mental
Health In-Reach Team caseload will be discussed at the October 2009 team
meeting.
To the Governor, HMP Manchester:
7. The Governor should encourage the CARATs team to develop a centralised
system for identifying and reminding staff of prisoners’ release dates.
The Prison Service has accepted this recommendation and a system has been
implemented.
8. The Governor should revise the current discharge procedures to ensure a cross-
disciplinary approach is adopted.
This recommendation has been accepted. The current discharge procedures will
be reviewed to consider including more members of the multi-disciplinary team.
9. The Governor should allocate a suitably private room for holding discharge boards.
The Prison Service has accepted this recommendation. During the review of
discharge procedures, the location of the discharge boards will also be considered.
25