Individual at Grendon

Investigation into the circumstances surrounding the
death of a man at HMP Grendon
in September 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2010
This is the report of an investigation into the death of a man. He was found hanging
in his cell at HMP Grendon in September 2009. He was a life sentenced prisoner,
having been convicted of the manslaughter of his partner in 2000. He was 47 years
of age.
I extend my condolences to those who knew the man and I hope that my report goes
some way to answering their questions. I apologise for the delay in completing this
report.
The man’s death is the first to have occurred at HMP Grendon since the
Ombudsman started investigating deaths in custody in April 2004. I understand that
the previous self inflicted death at the prison was 16 years ago.
The investigation into the death was undertaken by an investigator. A clinical review
was conducted by a clinical reviewer on behalf of the local Primary Care Trust
(PCT). I am grateful to him and his review is annexed to this report. I would also like
to take this opportunity to thank all of the staff and the Governor at Grendon for their
cooperation with the investigation.
The man had a history of harming himself. He refused food on several occasions in
protest as he had been in prison for longer than his tariff and had been unsuccessful
in his bid for parole. He moved 19 times in the ten years that he was in custody, a
number of which were at his own request. He appears never to have settled at any
one establishment, frequently asking to be transferred to other prisons as soon as he
got to a new prison.
On his transfer to Grendon the man appeared to settle, but quickly became
disillusioned, refusing to participate in the therapy that the prison had to offer.
Alerting staff that he was not eating, firstly because of constipation and then to avoid
returning to HMP Rye Hill, staff opened Assessment, Care in Custody and
Teamwork (ACCT) monitoring and opened a food refusal form. However, he started
to eat again the evening before his death. I make a number of recommendations in
my report relating to the emergency response by staff when they discovered him.
During his time in prison custody the man had a well documented history of harming
himself, history of food refusal and masking his true feelings. I believe that staff at
Grendon were not fully aware of the turmoil that he was suffering and his state of
mind at the end of September 2009.
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 August 2010
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CONTENTS
Summary
The Investigation Process
HMP Grendon
Key Events
Clinical Review
Issues
Conclusion
Recommendations
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SUMMARY
The man, who had a history of suicide and of harming himself, was remanded in
custody in December 1999. In June 2001, he transferred to HMP Grendon.
However, having been considered unsuitable for its therapeutic regime, he
transferred back to HMP Wormwood Scrubs.
Over the following years the man transferred prisons a number of times before
arriving at HMP Buckley Hall in January 2006. Staff opened an Assessment, Care in
Custody and Teamwork (ACCT) document as he had written to a friend that he
wanted to end his life, as he believed he would never be released from prison. (The
ACCT system is used to assess, observe and support prisoners at risk of harming
themselves.)
Between 2006 and August 2008, the man made many applications to transfer
prisons, some of which were successful. However, he appears not to have settled in
these prisons and, either due to his own request or as a consequence of his
behaviour, was transferred a further six times before arriving at HMP Rye Hill on 5
August. During this time staff opened two more ACCTs due to threats he made
against himself and instances of food refusal.
The man appears to have settled quickly at Rye Hill. He complied with the prisons
rules and regimes and, having got a job, told staff that he was happy having
something constructive to do. However, in early November, he alleged that he had
been bullied by another prisoner on the wing. He asked for no action to be taken
and declined to move to another unit. He made no further complaints about bullying
whilst he was at Rye Hill.
In May 2009, the man requested a transfer back to Grendon, saying that he felt he
would benefit enormously from its therapeutic regime. On 20 July, he was accepted
as being suitable for Grendon and arrived there on 28 July. During his induction he
told staff that he had previously attempted to commit suicide, and had gone on
hunger strike as he felt sorry for himself and saw other prisoners released on parole
before him.
During his first weeks at Grendon, the man attended the prison’s community group
sessions, partaking in therapeutic discussions. However, by the middle of August,
he began to withdraw from the meetings, at first by not actively participating and
latterly by not attending. On 4 September, he expressed a wish to return to Rye Hill.
His behaviour deteriorated and, on 14 September, he was sacked from his cleaning
job.
On 20 September, the man complained to a nurse that he could not eat due to
constipation and, as a consequence, had been giving his meals away for the
previous eight days. The nurse contacted wing staff and asked them to observe
whether or not he was giving his food away.
Later that day, due to his request to withdraw from therapy and his behaviour, the
man was told that he would be returning to Rye Hill. Another prisoner described him
as ambivalent about returning as he wanted to leave Grendon but believed that he
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did not want to return there. He thought something concerned him about going back.
The following day, 24 September, the man was seen by a psychiatric nurse, having
told a student nurse earlier in the day that he was depressed, frustrated and wanted
to end his life by refusing food. The psychiatric nurse noted his eloquence in his
desire to refuse food as a means of taking his life. In addition to notifying wing staff,
the nurse referred him to be reviewed by a member of the mental health in reach
team (MHIRT) the following morning.
Wing staff immediately opened the ACCT procedures and various support plans,
including one from healthcare, were put in place. Staff started a food refusal form to
monitor whether the man ate the meals provided. The following morning, 25
September, he was assessed by a member of the MHIRT. The nurse noted that he
said he “had had enough”, citing his harsh treatment and the unfairness of the prison
system as triggers for his food refusal. However, he also told the nurse that he was
too scared to deliberately harm himself.
The man refused his lunch that day but was seen eating his meal that evening, as
well as taking a quantity of biscuits back to his cell. He was checked as required in
his ACCT document. It was during one of these routine checks at 1.40am that he
was found in his cell, having tied a ligature around his neck. Staff went into the cell
to assist him. However, he was pronounced dead soon afterwards.
My investigator established that the man received good care whilst he was in
custody at Grendon. However, some concerns are highlighted in my report about
the way staff dealt with the emergency. In particular, with regard to entering his cell
when he was discovered hanging and calling an ambulance. Although I am satisfied
that these issues had no direct impact on his death, they highlight a number of areas
in which improvements could be made to the emergency response.
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THE INVESTIGATION PROCESS
1. The investigation into the circumstances of the man’s death was carried out by
one of my investigators. He opened the investigation on 2 October 2009 when
he visited HMP Grendon. He met the Governor of Grendon, the Head of
Therapeutic Services, and the Head of Residence. He also met two members
from the Prison Officers’ Association and a member of the Independent
Monitoring Board. (IMB members are independent and unpaid. They monitor
day-to-day life in the prison to ensure that proper standards of care and decency
are maintained.)
2. Notices announcing the investigation and its terms of reference were issued to
both staff and prisoners at Grendon. The notices were displayed around the
prison and invited staff and prisoners to contact the investigator should they wish
to do so.
3. My investigator was shown the cell and wing where the man spent the last
weeks of his life. He reviewed the man’s prison and health records and other
documentation relating to the time that he spent at Grendon. He also visited the
prison on several occasions to carry out interviews with staff and prisoners. My
investigator was assisted by another of my investigators when interviewing staff.
During the course of the investigation my investigator provided verbal and
written feedback to the Governor.
4. My investigator also had access to transcripts of telephone calls made by the
man to a friend. (The content of these telephone calls were not known to staff
before his death. Only a small percentage of telephone calls made by prisoners
are monitored. When calls are monitored they are usually for reasons of security
or child protection. He did not fall into these categories.)
5. My investigators also spoke with a member of the therapeutic community, of
which the man was a member. Although no other members of the community
came forward individually to speak with the investigators, some did speak with
the Senior Officer (SO), who kindly liaised on the investigators’ behalf.
6. An independent clinical review was undertaken on behalf of the local PCT by the
clinical reviewer.
7. My investigators spoke with a Detective Constable from Thames Valley
Constabulary, who is acting on behalf of the coroner. My investigator has also
been in contact with the coroner’s office and a copy of this report will be sent to
Her Majesty’s Coroner for Buckinghamshire to assist his enquiries. A copy of
this report will also be sent to the National Offender Management Service, the
organisation that oversees the Prison Service.
8. One of the Ombudsman’s family liaison officers contacted the man’s next of kin,
a friend of his, to discuss the scope of the investigation and give him the
opportunity to raise any questions or concerns about the man’s death. He asked
why he served so long in prison and was not released on parole. I hope that this
report helps address his concerns and any other issues that remain unclear,
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helping him to better understand what happened in the time leading to his
friend’s death.
In response to the issuing of the draft report the man’s friend raised a number of
issues and concerns. These included that annexing the clinical reviewer’s
clinical review, and not incorporating its contents in the report, was a distressing
omission. How it was that the clinical reviewer observed that the 19 times that
the man was transferred between prisons were largely un-documented, but that
the Ombudsman’s report states that these moves were made at his own request.
That information was not sought from the man’s Member of Parliament to whom
he complained about his difficulties at Rye Hill in 2008. Difficulties in relaying his
concerns to the prison authorities after visiting him in September 2009 and why
he had not progressed towards release having served his three and a half year
tariff. The man’s friend also questions the professional confidence of some staff
and whether the man received satisfactory care whilst in custody.
Although I have addressed a number of these concerns in my report, one of my
family liaison officers has addressed the remaining concerns raised by the man’s
friend in separate correspondence.
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HMP GRENDON
9. HMP Grendon is a Prison Service Democratic Therapeutic Community or
therapeutic community (TC) for short. Grendon is the only prison in the country
to be run entirely on therapeutic principles and accepts some of the most
challenging and disruptive men in the prison system. The regime offers
prisoners (or ‘community members’ as they are known), the opportunity to
address their offending behaviour and other related problems. Grendon’s aim is
to help them reduce their offending in order to lead more positive lives. As much
responsibility as possible is given to community members who are in turn
encouraged to take personal responsibility for their actions.
10. Community members at Grendon meet up to three times a week to discuss
offending behaviour and manage domestic and regulatory matters related to
living together. Staff are expected to support the TC in democratic decision
making and to role model pro-social behaviour. Additionally both staff and TC
members challenge and provide feedback about anti-social behaviour.
Members are encouraged to practice new ways of behaving and deal with their
problems more effectively.
11. Before prisoners can be accepted as full members of the TC, they are required
to undergo an induction assessment to establish whether or not they are suitable
for the regime and its therapies. Even before being considered for assessment,
prisoners are made fully aware that, should they not be accepted at Grendon or
decide to leave, they will return to the prison from which they came.
12. At the time of the man’s death the Induction and Assessment Unit had been
temporarily relocated to G wing while F wing, its normal location, was being
renovated. During the induction, prisoners attend community meetings for an
hour and a quarter each Monday and Friday morning. The meetings are also
attended by officers and other staff including psychologists, chaplains and
educationalists, if they are available. Smaller group meetings are held each
Wednesday and an additional meeting is held on Thursdays when unit business
is discussed. Official minutes of the meeting are not kept, due to reasons of
confidentiality. However, general observations are recorded about individual
prisoners by wing staff.
13. Primary healthcare at Grendon is provided by the local PCT with the mental in
reach being commissioned from the Mental Health Trust. There is no 24 hour
nursing cover.
14. The last full inspection of Grendon by Her Majesty’s Chief Inspector of Prisons
was an unannounced short follow-up inspection between 31 October and 2
November 2006. She reported that overall Grendon was:
“… an impressive prison which does remarkable work with some of the most
challenging prisoners in the system … the health and importance of the
prison is not in doubt.”
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15. In 2006, research from Oxford University was commissioned, as a consequence
of a recommendation made by HM Chief Inspector, to explain the
disproportionately low rates of suicide and self harm. The incidence of self harm
at Grendon in the period 2005-06 was only 29 per thousand prisoners,
compared with 133 per thousand in the remainder of the male prison estate in
2005. The report concluded that there was evidence that the therapy
programme offered by Grendon reduced prisoners’ feelings of hopelessness and
encouraged optimism about the future.
16. The Assessment, Care in Custody and Teamwork (ACCT) process operates in
all prisons and aims to monitor and support prisoners who are assessed as at
risk of suicide or self harm. Once an ACCT is opened, the prisoner is observed
at pre-determined intervals according to their perceived level of risk. ACCT
review meetings take place and the prisoner’s progress and risk is reviewed by a
multi-disciplinary team of staff who know the prisoner or are involved in their
care.
17. The man’s death was the first apparently self-inflicted death in Grendon since
the Ombudsman took on the responsibility for the investigation of deaths in
custody in April 2004. I understand that it is the first apparent self inflicted death
to have occurred at the prison for 16 years.
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KEY EVENTS
18. The man was 47 years old when he died. He had a history of assault and had
received custodial sentences as a consequence. He also had a history of self
harming. In 1988 he cut his wrists and in 1990 he was hospitalised for four days
after taking an overdose.
19. On 24 December 1999, the man was remanded into custody at HMP Exeter,
having been charged with the murder of his partner. He was subsequently
sentenced to life imprisonment on 22 June 2000. His tariff, the minimum amount
of time that he was required to serve before being considered for release by the
Parole Board, was three years and six months. His first Parole Board hearing, in
August 2003, recommended that he remain in closed conditions. At his second
review in March 2006, the Secretary of State considered that he should remain
in closed conditions, although the Parole Board had recommended a transfer to
open conditions.
20. The man was transferred to HMP Wormwood Scrubs on 1 August 2000. On 19
June 2001, he was transferred to Grendon. However, he was not accepted as
suitable for Grendon’s therapeutic regime and, on 31 August, he transferred
back to Wormwood Scrubs. Between October 2001 and January 2006, he was
moved a further four times within the prison estate before his arrival at HMP
Buckley Hall on 16 January 2006.
21. The same day staff at Buckley Hall opened an Assessment, Care in Custody
and Teamwork (ACCT) document because the man had written, to a friend
about his intention to end his life once he had worked out “… the best way of
doing it”. (This was the first time that he had been subject to ACCT procedures.)
He told staff said that he believed he would never be released from prison, as
other prisoners given life sentences at the same time had already been released
on parole. He remained under closer supervision under ACCT procedures for
the following five weeks. Having reassured staff that he had no further thoughts
of harming himself, the ACCT procedures were closed on 24 February.
22. The man was transferred from Buckley Hall to HMP Coldingley on 5 June 2007,
and onwards to HMP Highpoint on 19 June. Although applying for an immediate
transfer on his arrival at Highpoint on 12 July, he told staff that he now wished to
stay at the prison. However, on 22 July, he changed his mind and asked to
transfer to HMP Wayland. He told staff that Highpoint was making him
depressed due to less freedom and poor food.
23. The man made further applications for transfer to Coldingley and Buckley Hall in
order to receive physiotherapy for an on-going back complaint, which he said he
could not get at Highpoint. He was briefly moved to HMP Norwich on 23
November, as a consequence of an administration error regarding a transfer to
Wayland. However, he returned to Highpoint five days later and remained there
until 14 February 2008. He continued to complain about the treatment he was
receiving from healthcare for his back problems. He applied for another transfer,
this time to HMP Ashwell, where he believed the healthcare would be better.
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24. On 30 November 2007, frustrated at the delay transferring to Wayland, the man
became aggressive and smashed a television set in his cell. He told staff that he
had tried to strangle himself the previous day and intended to starve himself to
death. Staff immediately opened an ACCT. He said that his sentence was
“becoming a nightmare”, that he would die in prison and would one day succeed
in ending his life early. He was for the second time monitored under the ACCT
procedures. He received, amongst other support, input from members of the
MHIRT. Over the following weeks his mood improved and, having stated to staff
that he was eating normally and had no further thoughts of harming himself, the
ACCT document was closed on 10 December.
25. The man began to repeat his concerns and frustrations about moving to
Wayland on 6 January 2008. He walked out of a psychology interview the
following day, saying he wanted nothing to do with Highpoint. On 8 January, he
again told staff that he had not eaten for several days, saying the food at
Highpoint was terrible and he could not eat it as the prison had the worst
hygiene he had ever seen. Healthcare staff were informed of his food refusal
and monitoring procedures were put in place. On 10 January, he was told that
his request to transfer to Wayland was being considered and the situation would
be helped if he started eating again. He explained that he had not eaten much
because he did not like the food, but would make the effort to eat regularly.
26. On 22 January, the Parole Board wrote to the man confirming his request for a
deferral in his hearing, which had been due to take place in March 2008,
because of his transfer to Wayland. The Board advised him that his next
hearing would be in September.
27. The man was transferred to Wayland on 14 February. However, by 16 March,
his behaviour at the prison had deteriorated significantly. He ripped a wooden
barrier from the wall of an office and barricaded his cell. As a consequence of
his actions, he was moved to the prison’s segregation unit.
28. During an interview on 1 April, the man told staff that he was feeling down and
had thought about hanging himself the previous evening. He said that he had
not eaten for two days and talked negatively about the future, saying that he
would rather kill himself than spend the rest of his life in prison. Officers
immediately opened the ACCT procedures and he remained under supervision
until he was assessed as being no longer at risk of harming himself. The ACCT
document was closed on 18 April. However, on 21 April, it was reopened when
he was found in his cell having cut his wrists and telling staff that he had been
talking to his dead sister. Once again he remained under observation on an
open ACCT. By 19 May, he was assessed as stable, chatty to staff, in good
spirits and displaying a normal pattern of behaviour. As a consequence of his
continued improvement the ACCT document was closed.
29. The man continued to express his wish to be transferred and, on 24 April, he
requested a further transfer to Buckley Hall. On 2 May, he was told about a
possible transfer to HMP Stocken, and it was noted in his history sheets that he
was receptive. He transferred to Stocken on 22 May. Although his ACCT
document had only recently been closed, he told staff before the transfer that he
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did not feel vulnerable or at risk of harming himself.
30. The man settled quickly at Stocken. Staff regularly noted in his prison record
that he raised no problems or concerns and appeared in good spirits. However,
on 14 July, he told staff that he wanted a further transfer. He was told that was
not an option as he had moved three times already during the period of his
current parole application. He was advised to settle down, improve his
behaviour and gain employment, in order to assist his application for parole.
However, staff noted that he was not happy with this advice.
31. On 17 July, the man barricaded his cell and was removed, under restraint, to the
prison’s segregation unit. He told staff that his actions were a consequence of
his frustrations and wanting a transfer to HMP Erlestoke. He was told that his
security category was to be upgraded from a category C to a category B
prisoner, a retrograde move. He admitted to staff that he had a number of
“issues” which needed to be addressed and that he had “… not been in the right
place” for sometime. (Category B prisoners are those for whom the highest
security conditions are not necessary, but for whom escape must be made very
difficult. Category C prisoners are those who cannot be trusted in open
conditions but who would not have the ability or resource to make a determined
escape.)
32. As a result of his re categorisation the man was transferred to Rye Hill on 5
August, where he settled quickly. He got a job, and said that he was happy that
he had something constructive to do. He complied with the prison’s rules and
regimes, was polite to staff and associated well with other prisoners.
33. In early November, he alleged that he had been bullied by another prisoner. He
told staff that he did not want the perpetrator to be spoken to in case it made
things worse for him, or for the anti bullying strategy to be put in place as
prisoners were already calling him a “grass”. However, he declined to be moved
to another wing and agreed to tell staff about any further incidents. He made no
further complaints about bullying during the remainder of his time at Rye Hill.
34. On 20 November, the man asked for his third parole hearing to be deferred for
six months. He said that this was due to obtaining new solicitor who was
unfamiliar with his case and proceeding would be a waste of time. However,
due to submitting his deferral papers late, the Parole Board hearing went ahead
as scheduled on 15 December. As a consequence of having no legal
representation, he represented himself.
35. On 29 December, the Parole Board reported on its consideration of the man’s
release and transfer to open conditions. The Board reported that he had
incurred 11 adjudications since his imprisonment, four in the previous year and
that he had been re-categorised from category C to category B following the
barricading of his cell. The Board also noted that he had failed to put into
practice work undertaken in a number of programmes to address his offending
behaviour. Also he had been transferred to a number of prisons but had not
settled. The forensic psychologist, with whom he terminated interviews and
refused to meet on numerous occasions, concluded that he should remain in
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closed conditions in order to undertake work to address his risk of violence
against his partner. The Board reported that his tendency to impulsive and
aggressive behaviour and difficulty deploying coping strategies, added to his
risk. A period of stability in one establishment would be required to build up his
coping skills and confidence. The Parole Board concluded that he should stay in
a closed prison and continue to work towards reducing his risk of re-offending.
36. During the remainder of the man’s time at Rye Hill, staff frequently described him
as polite, respectful and complying with all the rules and regimes. He was seen
as making excellent progress. In late January 2009, he made an application for
transfer to Grendon, saying to staff that he felt he would benefit enormously from
its therapeutic regime.
37. The man wrote to the Population Management Coordinator at Grendon on 25
May to ask how his application for transfer was progressing. He wrote that he
was six years post tariff and that Grendon was his only hope of a successful
parole hearing. She replied that, pending a screening process and review of
security issues, he would be told whether or not he was suitable for transfer.
38. On 20 July, the man was accepted as suitable for further assessment at
Grendon. He was told that, if accepted for therapy on completion of the
induction and assessment process, a commitment of two years and a willingness
to abide by the expectations of the community would be required. He was also
informed that, should he be accepted, he would have to forego any application
for parole for at least 12 months. This was because the therapy required a
commitment of at least 18 months. On 18 September, he signed a deferral form
confirming his wish to defer his Parole Board hearing for 18 months. On 28 July,
he transferred to Grendon and was allocated to live on the prison’s Assessment
and Induction Unit.
At HMP Grendon
39. On arrival at Grendon, the man was interviewed by an unidentified member of
staff who completed an initial assessment and induction form. He provided a full
history relating to his family and offence. He also provided details of self harm
attempts and previous therapy. He told staff that he had tried to commit suicide
previously by cutting his wrists. He said that he had done this because he felt
sorry for himself, seeing other prisoners being released before him and believed
that he would never be released. He said that he had gone on a ten day hunger
strike two years previously as a protest at being so many years over his tariff.
The rules and regimes were explained to him and he signed a number of
compacts acknowledging his understanding of them.
40. The man’s first community group session took place on 29 July, his first full day
at Grendon. He talked about his problems with alcohol, but denied being an
alcoholic.
41. On 30 July, the man made a telephone call to a friend. He explained how he
was settling in at Grendon and predicted that therapy over the next two years
would be demanding for him. He talked about sending out visiting orders to his
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friend and said that, compared with eight years ago when he was last at
Grendon, there was less freedom but the food was good. My investigator
thought that throughout the conversation with his friend the man sounded
relaxed and calm.
42. During his second community group session on 5 August, the man said little.
Towards the end of the session he wanted to pursue an issue but was unable to
do so as the meeting was ending.
43. A Registered General Nurse (RGN) completed a healthcare admission
questionnaire on 6 August. The man told the nurse that he had an elbow pin
and suffered from a back injury. The nurse documented that he had a previous
history of depression, harming himself and had attempted suicide. However, the
nurse noted that he was not receiving any treatment at the time of his transfer to
Grendon.
44. The man was visited on the induction wing on 7 August by a mental health
nurse, a Registered Mental Nurse (RMN). He recorded that the man expressed
no immediate health concerns and denied any suicidal thought at that point.
45. Shortly after lunch on 8 August, the man telephoned his friend again and said
that things were going as well as they could. They talked about contacting his
new barrister and his friend reassured him that everything would be okay. He
suggested that the man write to bring his barrister up to date. He told his friend
that people at the prison did not understand and talked of the prison’s
inefficiencies. He said he was not fortunate enough to have a good solicitor to
represent him. Later that afternoon he called his friend again, advising him that
he had arranged for visiting orders to be sent out. He talked of other prisoners,
who had received higher tariffs than himself, but had already been released from
prison.
46. On 10 August, the man spoke with his friend once again, seeking additional
information in order to complete the visiting order. In a telephone call two days
later, he again spoke about arranging a visit to the prison.
47. A prisoner, who was a member of the man’s community on the induction unit,
told my investigator that they often spoke together. The man had told him on
one occasion that he was unhappy with his legal representation. The prisoner
provided him with the contact details of his own solicitor. He said that the man
had learnt recently of the reasons for his parole refusal, believing that this had
been a “turning point” for him.
48. Four days later, on 14 August, the man was assessed by one of the prison
doctors. She told the investigator that he had made an appointment as he was
suffering from lower back pain, which he told her he had experienced for the
previous ten years. He said the pain had been affecting his sleep and he
wanted to see a chiropractor. She referred him to the prison physiotherapist.
She said that he expressed no other concerns during the consultation.
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49. At the man’s third community group session on 12 August, he discussed the
death of his sister through drug abuse, challenging another prisoner about his
own addiction. He also revealed to the other prisoners that he had issues
relating to trust and struggled to disclose personal feelings.
50. On 19 August, after the man’s fourth group meeting, staff noted that he found it
difficult to open up, was defensive and did not believe he would be at Grendon
for long.
51. An officer completed an Assessment Unit Progress Report on the man. It noted
that the man was, “Being closed down to the community, keeping himself to
himself and suspicious of others, point scoring. Struggling to build upon
relationships.” The officer noted that the man felt angry about a previous refusal
for a transfer to an open prison and that he was five to six years over tariff. He
was set a number of targets including becoming more trustful, engaging in
community activities and avoiding feelings of injustice.
52. On 26 August, during the man’s fifth group session, staff recorded that he said
very little, challenging a prisoner who felt his sentence was harsh, but listened to
others in the group.
53. An officer wrote in the man’s wing history sheets on 27 August that he had
spoken of his wish to return to Rye Hill because he did not need to engage in
therapy. However, after further consideration, he decided that he would
continue the assessment period at Grendon.
54. At the man’s sixth and final group session on 2 September, staff noted that he
did not speak until the end. When asked why, he said that he had issues with
regard to trust and paranoia, expecting people in authority not to do the right
thing.
55. On 4 September, the officer again recorded the man’s wish to return to Rye Hill.
The officer noted that he became annoyed with staff after they told him that an
incorrectly addressed postal order would need to be returned to the sender.
In response to the draft report the man’s friend said that on 5 September 2009,
he and a friend visited him in prison. He said that it was apparent that he was
vulnerable and at risk. The man’s friend says that a notice invited visitors to
phone a named member of staff should they have any concerns. He said that
he telephoned the number the following week and was told that as the staff
member named on the notice had been transferred to other duties he should
speak to staff on the man’s wing. Having spoken to staff on the wing he said he
was advised that he should write to the Governor. He did not write to the
Governor believing that he would require the permission of the man to do so. He
said that he did not speak with the man again.
My investigator spoke to Grendon’s Safer Custody Manager about the notices.
She confirmed that notices were displayed inviting friends and family to contact
the prison should they be worried about someone in prison. She confirmed that
the posters were in place when the man was at Grendon.
15
The posters invite staff to contact the Safer Custody Manager, Duty Manager or
Duty Governor before leaving the prison, or to phone the prisons general
number asking to speak to the same. The poster also provides contact details
for the Prisoners’ Families Helpline and Samaritans, who would forward
information to the prison, if no member of prison staff was available.
56. Just over a week later, on 12 September, an officer recorded that the man, whilst
cleaning the staff office that morning, became negative about his job when he
was asked to place a ‘wet floor’ marker down. He told the officer that he did not
like the job anymore and walked out, returning to his cell. He explained his
actions to the officer the following day. He told the officer that he struggled to
trust staff due to previous experiences that had a negative impact on him. They
discussed the need for him to make his mind up whether to commit to Grendon
or return to Rye Hill. The officer went on to report that the man subsequently
arrived for work on time, carried out his duties to the required standard and with
an appropriate attitude.
57. However, on 14 September, another officer reported that the man again refused
to do his work and had now been sacked. The officer noted that the man had
repeated that he wanted to leave Grendon. It was also recorded that he was no
longer participating in therapy.
58. On 15 September and again on 23 September, the man failed to attend the
weekly group session.
59. The man went to healthcare on 20 September where he was assessed by a
RGN. She wrote in the medical record:
“Attended at treatments stating was constipated, hadn’t passed stool for eight
days. Also states had given meals away for those eight days as couldn’t eat
due to constipation. Advised fluids, roughage and increased exercise which
he states he can’t as he has a bad back. Contacted wing to ask them to
observe diet and if he is giving food away … “
She prescribed two tablets of Sennakot (a laxative) and advised him to return
should he need more. Given his presentation, she told the investigator that she
believed he must have been eating some food.
60. On 23 September, the man received physiotherapy for his back pain from the
prison’s physiotherapist. She wrote in his medical record that he was agitated
during the session and told her that he did not want to stay at Grendon.
61. An officer wrote in the unit’s observation book that an officer had spoken with the
man to advise him that he would be returning to Rye Hill. He noted that this was
requested by the man as he was withdrawing from therapy. The prisoner and
community member told my investigators that the man was very frustrated after
the meeting with the officer, saying that he did not want to return to Rye Hill.
The prisoner said the man seemed ambivalent about returning to Rye Hill,
although he wanted to leave Grendon. Nevertheless the prisoner felt that he did
16
not want to return. He said that the man told him that he was bullied by a Rye
Hill officer and something seemed to concern him about his imminent return.
62. At 3.35pm the following day, 24 September, a student nurse, having been
alerted by wing staff, spoke to the man, about why he had been collecting his
meals and throwing them away. He said he was depressed and frustrated due
to his lack of independence and was fed up with life, wanting to see his family in
the ‘after life’. The student nurse wrote that he was not eating but was drinking
four cups of tea a day. He said that he had not eaten for 13 days. He agreed to
be referred to a community psychiatric nurse.
63. Following the student nurse’s meeting, a RMN talked to the man at 4.00pm. She
recorded in his medical record that he was very eloquent in his desire to
continue with his food refusal as a means of suicide. He told her that he had felt
unsafe in previous prisons. He talked about staff corruption, bullying and that his
life had been threatened by other prisoners. He believed he had family waiting
for him in an “after life” and expressed strong religious convictions. He told the
nurse how he saw no future and that the final outcome for everyone was death.
However, he expressed no suicidal ideas saying that he felt safe on the
induction wing. She explained that the prison had a duty to provide him with a
mental health assessment and that, due to his food refusal, checks on his
physical health would be taken. She also referred him to be assessed by a
member of the MHIRT the following morning.
64. At 4.45pm, an officer spoke with the man, following his appointment with
healthcare staff. He told the officer that he had not eaten since 12 September
and that it was his intent to starve himself to death, believing in an “after life” and
“as a way to end it all”. The man added that he would not harm himself in any
other way. At 4.55pm, shortly before being locked back up in his cell, the officer
spoke with him again. He told the officer he was adamant that he would not eat
again and had told healthcare about this. When advised of the various support
plans, he said he did not want “all this attention” and did not want to be put on an
ACCT.
65. The officer opened ACCT procedures at 5.15pm. As part of the ACCT process,
staff agreed an immediate action plan. This included the man remaining in his
current cell where he felt safe, and being offered the support of other members
of the community and staff. The required frequency of observations and
conversation were set as once in the morning, afternoon, evening and during
routine patrols at night.
66. A food refusal form was started. (The form is used by the Prison Service to
monitor whether the meals provided to a prisoner are eaten.) It was recorded on
the form that the man had been offered his evening meal but declined to take it.
He remained in his cell during the evening watching television, and caused no
concern to staff. He was checked another four times during the night and was
each time asleep. Another officer wrote in the unit observation book advising
staff that the man was to collect his food from the wing office and it was to be
recorded in the food refusal log. The officer also wrote that, if he refused food
for 72 hours, healthcare staff would take over his care and he would be subject
17
to daily urine tests to confirm whether or not he had eaten.
67. At 6.30am on the morning of 25 September, the man signalled, when checked
by an Operational Support Grade (OSG) that he was okay. At 8.15am an officer
spoke with him and they discussed the television programmes that he had
watched the previous evening.
68. The man went to healthcare to provide a urine sample at 8.45am. A RGN noted
that the sample showed significant abnormalities. The nurse noted a high level
of ketones, suggesting that he had not been eating properly recently. (Ketones
are produced normally by the liver as part of fatty acid metabolism. In normal
states ketones will be completely metabolised so that very little, if any, appear in
the urine. If someone does not eat for more than a few hours then the body will
run out of glucose [sugar] stores and will switch to breaking down fats and
produce ketones.) At 10.00am the man told an officer that he was happy with
the support he was receiving from staff on the unit.
69. The man was interviewed by a nurse and manager of the MHIRT, at 10.30am.
He told the nurse that he had been on hunger strike for two weeks and had “had
enough”, citing his harsh treatment and the unfairness of prison as triggers to his
decision to refuse food. He said he had no other plan to end his life and was
scared of deliberately harming himself. The nurse noted that he was relaxed
and pleasant during the assessment, maintained good eye contact, coherent
speech and concentration. The nurse encouraged him to attend his ACCT
reviews and offered weekly one to one sessions for support and to discuss
coping strategies. He told my investigator that he did not believe the man was
suffering from any severe or enduring mental illness, but from depression. He
said that the man had asked to be sent back to Rye Hill as he no longer wanted
to stay at Grendon. The nurse said that he appeared keen to go back.
70. An officer completed an ACCT assessment interview with the man at 11.30am.
The man said that he had had no contact with his family and only little contact
with two religious friends. The officer wrote in the review that the man “… has
the feeling that death and his belief in the after life is an escape from prison as
he has no chance of release from prison in the future.” The officer noted that he
had no trust in the prison system saying that he was victimised and staff were
corrupt. The man told the officer that he was anxious about his imminent return
to Rye Hill, adding that he only felt safe and trusted the staff at Buckley Hall.
71. At 11.55am a second officer provided the man with his packed lunch shortly
before being locked in his cell. The officer told my investigator that she was
surprised when she learnt that he had been refusing food since 12 September,
as his appearance did not indicate this. At 1.20pm a third officer asked him if he
had managed to eat any of his lunch and he replied that he had not as he was
not yet ready to do so.
72. An assessor chaired the man’s first ACCT case review at 1.37pm following his
earlier assessment interview. The second and third officers also attended. At
the meeting the man talked of his feelings of anger, helplessness and bitterness.
He said he felt he would never be released and saw no way forward, raising
18
issues regarding his perceived injustice. He told the officers that he was
misunderstood and, although staff were supportive, he felt isolated and
exhausted. The care plan was updated and the next ACCT review was
scheduled to take place on 28 September.
73. In interview the second officer told my investigator that she believed the man
was unhappy at Grendon, wanting to go to Rye Hill. However, she said that
when he was told he would be returning, he changed his mind claiming that he
did not want to be sent back. She said she did not believe he really wanted to
be at Grendon in the first place and may only have come to the prison in order to
satisfy the Parole Board.
In response to the draft report the man’s friend says that having been involved in
the man’s request to transfer to Grendon and having made telephone calls on
his behalf he is of the view that the second officer misread the man’s motivation
and purpose.
74. At 4.15 pm the third officer noted in the ACCT on-going record, wing observation
book and food refusal log that the man had collected a full plate of food from the
servery and was eating it. He also noted that he had taken a quantity of biscuits
back to his cell.
75. A fourth officer checked the man at 8.30pm. He recorded that he was sitting in
his cell in the dark watching television and gave no response when asked if he
was okay. The officer said his behaviour did not unduly concern him, adding
that prisoners frequently ignored staff when they were checked at night.
However, the officer explained that if he had had any concerns he would have
raised them with the duty manager immediately. He told my investigator that the
man appeared to be very suspicious and hostile towards uniformed staff, kept
himself to himself and did not particularly mix with other prisoners. At 8.55pm
the OSG similarly noted that he was in bed under his blanket, in the dark. He
said that his television was on, but he said nothing to him.
76. In the early hours of 26 September, the OSG began his routine checking of the
unit which included checking the man. At 12.00am the OSG once again noted
that he was in bed, under his blanket and the television was on. The OSG said
that, although he did not speak with him, he saw that he was breathing.
77. The OSG checked on the man again at 1.40am. On opening the cell’s
observation flap, he saw him sitting on the floor with his legs out in front of him.
He told my investigator that:
“… a sheet was round his neck and his head was tilted to the right and
obviously the sheet had been attached to the window, and the chair and the
tables and everything, obviously had been moved around. I banged on the
window a couple of times and I turned the light switch on a couple of times,
but I knew he was dead then because obviously there was no movement at
all, so straightaway I got on to my radio, I got in touch with control and I said
to them this is Bravo five urgent message, I said could you get all the staff to
come down to the wing immediately …”
19
The OSG returned to the area in front of the unit office to await the arrival of
assistance.
78. A Senior Officer (SO), Oscar 1, was in the staff mess when he heard the OSG’s
request for him to attend G wing. (During night shifts in prisons, the most senior
officer, commonly known as Oscar 1, is responsible for the running of the
prison.) Whilst making his way to the wing he met a fifth officer, who was also
responding to the call for assistance.
79. Arriving on the wing at 1.42am, the officers were met by the OSG who told them
a prisoner in cell 4-07 was having problems. The SO enquired as to the problem
and was told by the OSG that he thought the man was dead. The three officers
made their way to the landing gate, beyond which the man’s and other cells
were located. The SO asked the OSG to open the landing gate. (Because cells
at Grendon do not have in cell sanitation, each landing has an additional locked
gate. This allows prisoners to be let out of their cells to access the toilets during
the night, but not to have access to the main wing. If a prisoner has been let out
of his cell to go to the toilet, officers are unable to access this landing.)
80. The SO said that he arrived at the man’s cell within approximately 30 seconds of
arriving on the wing. On looking through the observation flap, he saw that he
was slumped, sitting at the back of the cell with a green bed sheet tied around
his neck. The SO told my investigator that, by the way he looked and based on
his own previous experiences, he believed he had already died. The SO
immediately asked a sixth officer, the control room operator, to electronically
unlock the cell door.
81. At approximately 1.43am the SO and the fifth officer went into the cell. The
officer attempted to lift the man from the floor, to assist the SO in cutting the
ligature free. Unable to take his weight, she was assisted seconds later by a
seventh officer who had also responded to the call for assistance. Having cut
the ligature free, the officers laid the man on the cell floor. Despite his own belief
that he was dead, the SO asked the seventh officer to check for vital life signs
and to start cardio pulmonary resuscitation (CPR) while he left the cell with the
fifth officer to call an ambulance.
82. On his arrival on the wing an eighth officer assisted the seventh officer. The
officers established that the man showed no signs of life, had no pulse, was very
cold and both his eyes and mouth were fixed. The officers told my investigator
that there were clear signs of rigor mortis which made CPR impossible. The
officers placed a blanket over him and left the cell, returning to the wing office to
await the arrival of the paramedics. The OSG confirmed that after the arrival of
the officers he did not enter the cell or assist with CPR, but returned to the wing
office as instructed by the SO.
83. The control room incident log records that an ambulance was called at 1.43am.
It arrived at 2.00am and the paramedics were escorted to the wing on foot,
arriving at around 2.06am. The man was pronounced dead by the paramedics
20
at 2.10am.
84. A hot debrief was held later that day and was attended by staff who had been
involved in the discovery of the man. I also understand that the staff care and
welfare team approached those members of staff which was very much
appreciated by all of the staff with whom my investigator spoke. A review of all
prisoners on open ACCTs was also completed by members of the safer custody
team.
85. The man’s next of kin, a friend, was told of his death that afternoon by the
prison’s family liaison officer and duty governor who travelled to London to break
the news. Grendon offered funeral expenses and a memorial service was held
at the prison at which community members attended and took part in. The
man’s body was returned to London where he was subsequently buried.
21
ISSUES
Clinical care
86. In his clinical review, the clinical reviewer reports that the man presented with
chronic back pain for much of his time in prison and received appropriate
treatment, through physiotherapy, for the condition. He says that during the ten
years he spent in prison, the man received appropriate responses from primary
and secondary level healthcare services.
87. Suffering significant harm during the man’s early childhood due to the neglect
and abuse by his parents, the clinical reviewer says that this led to a complex
personality disorder in adulthood. He writes that, although he presented as
depressed at times during his sentence, the man did not appear to have a
clinical depressive illness. He reports that the man had a history of harming
himself and, during his time in custody, made numerous threats and gestures to
taking his own life. Although he had said he was too much of a coward to take
his own life, he often spoke of his wish to die. The clinical reviewer notes that,
although assessed as clinically depressed, the man was able to mask his true
feelings from staff.
88. The clinical reviewer reports that antidepressants prescribed to the man were
inconsistently collected, or that he would simply stop taking them. Finding that
they made little difference, he preferred to cope on his own. He says that
despondency and bitterness at his predicament led him to refuse food for
periods with the express wish that his life should end. This became more
frequent through 2008-2009.
89. In his clinical review the clinical reviewer says that no assessment of suitability
for psychotherapy in a therapeutic community, such as Grendon, was prepared
before his arrival at the prison. He reports that there was just one care plan, on
19 August, aimed to help the man engage in the therapeutic community whilst
he was there. This was in order to build trust and avoid feelings of injustice.
90. The clinical reviewer reports that the man was clearly unhappy at Grendon and
wanted to leave, possibly because he was more exposed to challenge from his
peers than he would have been in an ordinary prison. He says that, isolated
from his peers, he began to withdraw from the community, resulting in his non
attendance at community meetings in the weeks before his death. During this
time he became defiantly agitated about going back to Rye Hill, hoping for
another placement at a different prison. However, the clinical reviewer says that
there was no evidence of any work done with him around this area of
disappointment and future options, other than acknowledgment of his agitation at
his poor prospects. The clinical reviewer says no specific support was identified
to assist the man with this or with the decision to return to Rye Hill. He was
therefore left with this distress over his last weekend. However, the clinical
reviewer says that it was probably unlikely that a team meeting, planned for the
following Monday, but did not take place because of the intervention of his
death, would have affected a satisfactory alternative.
22
91. The clinical reviewer reports that some of the medical documentation was
confusing. In particular he says that the entry by the nurse, which was undated
but completed in the induction unit after the man’s arrival, was below standard.
He says that there was sufficient information,
“… known about the man on first assessment at Grendon to have alerted staff
to the high risk with his mental health and for them to make referral to the
psychiatrist for urgent review.”
He notes that the man was not seen for a general health screening until 6
August and that when assessed on the wing by the nurse, one of the mental
health nurses on 7 August, he was regarded as low risk for self-harm despite his
long previous history of significant mental health disorder. He concludes that
given the entry in the medical record it can only be assumed that the
consultation was brief.
92. The clinical reviewer says that the man had a history of refusing food as a
protest against the injustice that he felt and as a way to end his life, feeling too
cowardly to commit suicide. He said that the man’s previous recoveries and
ability to resume everyday life may have misled staff into thinking his actions
were manipulative. He said there was a suggestion of this in the uncertainty that
he was really discarding all food and in the evidence that he was not dehydrated
and appeared fine to staff. However, he notes that a regular check of his weight
loss would have confirmed his food refusal, as did the heavy presence of
ketones in the days leading to his death. The man lost almost ten kilograms in
weight in six weeks at Grendon, but notes that there were only two separate
measurement points recorded in his medical record. (My investigator could not
find reference to weight loss in the medical records). He says that it does not
appear that the man was monitored daily for food and fluid intake and output.
Blood pressure, pulse, weight and regular urinalysis were not taken as they
should have been, as should referral to the prison GP.
In his clinical review the clinical reviewer makes a number of
recommendations. I urge the Governor and Head of Healthcare to
consider the relevant findings carefully.
Assessment, Care in Custody and Teamwork training
93. During the investigation my investigator established that the second and third
officers, who took part in the man’s first case review, had not been trained in the
ACCT process, but nonetheless had taken part, by attending ACCT reviews and
writing directly in the on-going record.
94. PSO 2700, Suicide Prevention and Self-Harm Management, section 1.2.1 states
that,
“All staff in contact with prisoners must be trained to at least ACCT
Foundation level … be aware of the signs of risk … and when caring for
at-risk prisoners follow the ACCT procedures set out …”
23
95. I make no criticism of the officers. Who demonstrated a good understanding of
the ACCT process to my investigator. However, I am disappointed to learn that
they have not been provided with formal training.
The Governor of Grendon must ensure that all staff have received the
minimum of foundation level training in ACCT.
Emergency response
96. As I have already reported, the man’s death was the first apparently self inflicted
death to have occurred at Grendon for many years. As a consequence it is fair
to say that staff at the prison are not as well versed at dealing with such an
emergency situation as their colleagues in some other prisons. Although it
would appear to be clear that he had been dead for some time and it is apparent
that no intervention or indeed quicker response would have altered that
outcome, there are a number of lessons to be learnt in order to improve
emergency response systems for the future. I set these out as follows.
Delay in entering the cell
97. When he found the man hanging, the OSG raised the alarm but did not
immediately go into the cell. He returned to the main corridor to await the
assistance of responding staff. My investigator asked the OSG if there was any
reason why he had not entered the cell immediately he discovered the man.
The OSG said that he would never do anything like that, because he would
always make sure he had an officer with him. When asked whether he had been
told that another officer must be present before opening a cell, the OSG said:
“Yes, any incident you have got to make sure you have got an officer with
you. You never do anything on your own, you always make sure you have
got someone with you and I never entered the cell as soon as I saw him. Like
I say I went straight on to the radio and that was it and then I let all the officers
deal with it …”
98. My investigator reviewed Grendon’s local night instruction for dealing with a
suspected death in custody. The local instruction 2.87, June 2007, Nights –
Death in Custody/Suspected Death in Custody provides guidance on what action
staff should take. It states that on raising the alarm, the night patrol, having
contacted the control room, informing them of the cell location, “… must gain
access to the cell, if this is assessed as safe to do so” Having removed the
ligature from around the neck, they should give appropriate first aid. Similarly
the prison’s local policy for a Death in Custody states that on discovering a
prisoner who may have died, staff should immediately summon assistance and,
“Enter the cell / area (in these circumstances you may do so alone).”
99. The OSG said that he could see that the man had hanged himself. He
confirmed to the investigator that he was aware of the night procedures, but did
not immediately enter the cell to assist as stipulated in the procedures. It was
apparent to my investigator that the OSG was not fully aware as to the
circumstances of when he could enter a cell at night, and did not know the
24
actions to take following an apparent death in custody.
100. However, given the evidence of the other officers, it is clear that the man had
been dead for some time. Even if the OSG had entered the cell immediately his
assistance would not have altered the outcome. Nevertheless a prompt
response is essential, and in a similar situation, could save a prisoners life.
The Governor should remind all staff of the procedures and actions to be
taken at night upon discovering a death or suspected death in custody.
Emergency response codes
101. The SO was in the staff mess when he heard the OSG’s request on the radio for
him to attend G wing immediately. The SO said he was not aware of the nature
of the emergency to which he and the fifth officer were responding. He said he
walked to the incident, albeit quickly, but would have run had he known that the
man was found hanging.
102. My investigators discovered that there appeared to be a lack of awareness
amongst staff as to the emergency call signs. The OSG did not use a code
when requesting assistance. I understand that Grendon uses a level one, two
and three emergency code system. The SO said that level one was used to
alert staff of a hanging, level two, blood loss and level three is used for other non
life threatening situations. However, he told my investigator that he believed the
codes were not widely known by staff because they were seldom used. The
seventh officer’s understanding was that codes were used during the day when
healthcare staff were on duty and that at night there was no formalised code
system. Adding that if someone says “Oscar to G wing” everyone knows there is
an emergency and should attend immediately. The sixth officer, who was
working in the control room that evening, said that she was not aware of any
codes to be called in an emergency.
The Governor should remind all staff of the emergency calls to be used
when summoning assistance, throughout both the day and night.
103. Although I appreciate that there are no mandatory requirements for prisons to
use any specific emergency code system, many prisons use a call system such
as code red (for blood loss), code blue (for breathing difficulties) and code yellow
(for non life threatening). These codes inform staff of the nature of an
emergency in language that is easily understood. Although I make no formal
recommendation, I invite the Governor to consider whether or not the
introduction of such a system would assist staff when they are responding to an
incident.
Access to landing
104. The SO told my investigator that when he arrived on G Wing the landing gate
leading to the man’s cell was locked and he had to ask the OSG to open it. The
SO was surprised that the landing gate had not been left open in view of the fact
that a prisoner on the landing was having problems. He agreed with my
25
investigator that had another prisoner been let out of his cell to use the toilet,
during the time that the landing gate had been closed, immediate access to the
wing would have been compromised. Although the slight delay in accessing the
man’s cell would have not altered the eventual outcome, I make the following
recommendation.
The Governor should remind all night staff that upon discovering an
incident in a cell the landing door should remain unlocked in order to allow
immediate access.
Calling of an ambulance
105. The man was discovered by the OSG at 1.40am but it was only on the arrival of
the SO, three minutes later that an ambulance was called. It is essential that
ambulances are called immediately to life threatening situations. Any delay can
have a significant impact on a person’s chances of survival and the first on
scene should, having made an immediate assessment of the situation request
one should they believe it to be necessary. If not required the ambulance can
always be cancelled at a later time.
106. A Letter to Governors from the Director of Prison health in March 2004 advises
that:
“It is also essential that internal procedures should not waste undue time in
summoning emergency assistance. It should not for example, be a
requirement in every case for a member of the Health Care Team to attend
the scene before Emergency Services are called. However, a subsequent
999 call to the Ambulance Service should be made to cancel the response if,
after the original 999 call has been made, a member of the Health Care Team
arrives with the patient and deems that an emergency ambulance response in
not required.”
The Governor of Grendon should remind all staff of the importance of
calling an ambulance promptly.
107. This would be another benefit of using a coding system for emergencies as
highlighted earlier in my report. Some other prisons operate a system whereby if
the highest severity call is made an ambulance is automatically called
immediately by the communications room staff, leaving officers on the scene
free to assist.
First aid and defibrillator training
108. It became apparent during the investigation that, although a number of the night
officers had received previous first aid training, not all of that training, including
their CPR training was up to date. Although staff did not attempt to resuscitate
the man, speedy intervention by properly trained and qualified staff can often
make the difference between life and death. Had he needed resuscitation I am
confident that the officers present would have delivered it to the best of their
knowledge, based on their previous training. However, I think it essential that
26
discipline staff, in particular where there is no support from a night nurse, should
have the confidence and up to date knowledge to carry out first aid and CPR
effectively.
The Governor should provide training in first aid and cardio pulmonary
resuscitation for all staff who work permanent nights.
109. Several officers told my investigators that they did not know where the
defibrillator was kept in the prison. Access to any life saving equipment is critical
during an emergency and easy location, speedy recovery and prompt use is
essential. Given the evidence of staff who found the man, I do not believe that
using the defibrillator would have helped to save him. However, on another
occasion it might be critical.
The Governor and Head of Healthcare should review the location and
availability of defibrillator equipment at Grendon, ensuring that all staff are
aware of its location.
27
CONCLUSION
110. During his ten years in custody the man made many attempts to harm himself,
including refusing food to protest against the injustice he felt at not having been
granted parole seven years after his tariff had expired. In the latter years of his
sentence, this refusal of parole appears to have had a significant impact upon
his actions. His behaviour would on occasions deteriorate significantly and it is
apparent that he became difficult for staff to manage. The clinical reviewer
concluded that this behaviour, which was followed by recovery and to resuming
everyday life, may well have led staff to believe that the man’s actions were
manipulative. Although he was a demanding and sometimes difficult prisoner,
there is no evidence to suggest that this was the case.
111. In the weeks leading to his death the man, despite support from the community
at Grendon, appears to have withdrawn from active participation. His apparent
refusal to eat, which was only brought to the attention of staff in the days leading
to his death, appears to have been a mechanism, used on previous occasions,
to draw attention to his plight and inner feelings of uncertainty and insecurity.
Although staff opened the ACCT procedures, food refusal form and care plans,
and took time out to discuss with him his predicament, he appears to have
hidden his true feelings and intent to end his life from staff.
112. Both healthcare and discipline staff at the prison fully engaged with the man in
the days leading to his death. However, I do not believe that they could have
understood the impact on his failure to succeed at Grendon, and thus obtain
parole. Neither could the staff have understood how the knowledge that he
would return to Rye Hill had upon his thinking. It is perhaps only with the benefit
of hindsight that consideration can be made as to whether this disappointment
could have been better managed. I concur with the clinical reviewer when he
says that the man’s
“… death by suicide seems to have been an inevitable outcome for him as he
had indicated at times over the last three years within his predicament. The
prison system, he felt, had given him no support or hope for an alternative
life.”
113. I make seven recommendations, predominantly relating to the emergency
response. I also urge the Governor and Head of Healthcare to give further
consideration to the findings of the clinical reviewer in his clinical review.
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RECOMMENDATIONS
1. The Governor of Grendon must ensure that all staff have received the minimum
of foundation level training in ACCT.
Accepted - The establishment has in place a programme to ensure the delivery
of ACCT Foundation training to staff in accordance with PSO 2700, Prison
Service Standard 60 and the local Suicide Prevention & Self Harm Policy. The
implementation of the programme will be monitored by the Safer Custody Lead
and will be further supported by the training of extra staff to deliver the
foundation module. Once staff have received their initial training, they will be
required to attend a refresher within 3 years.
2. The Governor should remind all staff of the procedures and actions to be taken at
night upon discovering a death or suspected death in custody.
Accepted - The Governor will ensure the local procedures for the ‘Night State’
are subject to a full and comprehensive review, once completed the revised
instructions will be implemented and all staff, especially those at night will be
made aware of their responsibilities and actions expected of them in the event
of any emergency or incident.
3. The Governor should remind all staff of the emergency calls to be used when
summoning assistance, throughout both the day and night.
Accepted - The Governor issued instructions for staff (09/2009) informing of the
procedures to be followed in the event of an emergency. By following these
instructions, they will assist staff in responding effectively and efficiently to any
situation.
4. The Governor should remind all night staff that upon discovering an incident in a
cell the landing door should remain unlocked in order to allow immediate access.
Accepted - The Governor will ensure the local procedures for the ‘Night State’
are subject to a full and comprehensive review, once completed the revised
instructions will be implemented and all staff, especially those at night will be
made aware of their responsibilities and actions expected of them in the event
of any emergency or incident.
5. The Governor of Grendon should remind all staff of the importance of calling an
ambulance promptly.
Accepted - The Governor will ensure the local procedures for the ‘Night State’
are subject to a full and comprehensive review, once completed the revised
instructions will be implemented and all staff, especially those at night will be
made aware of their responsibilities and actions expected of them in the event of
any emergency or incident.
6. The Governor should provide training in first aid and cardio pulmonary
resuscitation for all staff who work permanent nights.
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Accepted - A review of the training needs of permanent night staff (officers &
OSG’s) identified areas where staff have become de skilled. Therefore, the
detailing of permanent night staff will cease by October 2010. Staff will work
rotational nights as part of a fixed shift pattern. The Staff Development Unit and
Group Managers will ensure staff working rotational nights receive First Aid &
Cardio Pulmonary Training.
7. The Governor and Head of Healthcare should review the location and availability
of defibrillator equipment at Grendon, ensuring that all staff are aware of its
location.
Accepted - Governor’s order 09/2009 was issued to inform staff of the current
location of the defibrillator equipment. Its location is subject to continued review
until a sufficient amount of staff are trained in its use.
8. I urge the Governor and Head of Healthcare to give further consideration to the
findings of the clinical reviewer in his clinical review.
Accepted - Director Of Therapeutic Communities will ensure the PCT are made
aware of the content of the report and that appropriate action(s) will be taken
where identified.
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