Individual at Altcourse

Investigation into the circumstances surrounding the
death of a man at HMP Altcourse
in March 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2010
1
This is the report of an investigation into the death of a man who died at HMP
Altcourse on 25 March 2009. The man was found hanging in his cell at
9.30am that morning; he had used a belt attached to his cupboard.
He was discovered by a member of staff who had gone to see why he had not
attended an education class. The officers on the landing responded quickly to
the emergency and were soon supported by their healthcare colleagues and
paramedics. Sadly, none of them could do anything to save his life. My
colleagues and I would like to extend our condolences to the man’s family and
all those affected by his death.
The investigation was carried out on my behalf by two of my collegues. I
thank the Director of HMP Altcourse, for the co-operation offered by his staff,
in particular by the prison liaison officer. As part of the investigation, a review
of the man’s clinical care in prison was carried out by a clinical reviewer on
behalf of the local Primary Care Trust (PCT), and I am also grateful to the
clinical reviewer for his assistance. Although the man’s clinical needs were
few, the clinical review has found that he appeared to become lost in the
healthcare system.
I make ten recommendations, the majority of which focus on healthcare and
the need for wider information sharing. There are five recommendations to
the Head of Healthcare at Altcourse which should be addressed in
consultation with the Director. Another recommendation to the Director
concerns attendance at suicide monitoring case reviews. There are two
recommendations to the healthcare provider regarding external agency
contracts and the electronic record system. Again, the Director should be
involved in relation to the agency contracts. I also make one recommendation
to the National Offender Management Service asking them to raise a matter
with the Law Society regarding solicitors correspondence.
As with all deaths in custody, the local police carried out an investigation of
their own. There were some delays in the police being able to finish their
interviews and there has been a consequent delay in my issuing this report for
which I must apologise.
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.
Stephen Shaw
Prisons and Probation Ombudsman March 2010
2
CONTENTS
Summary 4
The Investigation Process 6
HMP Altcourse 8
Key Findings 11
Issues Considered 27
Conclusion 35
Recommendations 36
3
SUMMARY
Prior to his arrest, the man who died is known to have harmed himself on at
least two occasions. When he arrived in prison the escort services had
already raised concerns about his self-harming behaviour which were passed
on to prison staff. Suicide and self harm monitoring procedures were put in
place from the moment he arrived at HMP Altcourse. He continued to be
monitored under Assessment, Care in Custody and Teamwork (ACCT) 1
procedures for nearly three weeks. During this time he had the support of
wing staff, the chaplain, a counsellor, carers2, and is said to have been able to
speak to his cellmate about any concerns.
The man’s ACCT was closed on 23 March, two days before his death. Whilst
being monitored on the ACCT, he did not harm himself and outwardly
appeared to settle well into the prison system – this was the first time he had
been in prison custody. To ensure that he settled and would be able to cope,
staff carried out a number of actions including allowing him a telephone call to
his employers, locating him on a stable and more mature wing, and arranging
counselling. Regular ACCT reviews were held. I make some observations
about the cross-section of staff attendance at the reviews and the necessity to
include a member of healthcare. I also found some issues with information
sharing, particularly by the counselling service. I do not attribute this as a
cause of the man’s death but it did demonstrate some gaps in the care and
treatment of prisoners.
In the week prior to this death, the man asked for paracetamol from officers
on several occasions and, on the day he died, from the nurse on the unit.
Individually, the dispensing seemed appropriate, however nobody was aware
of the overall picture. There is a gap here, in that there is no formal
monitoring by healthcare of who is getting paracetamol from uniformed staff.
Although this should apply to all prisoners it is especially important for those
on ACCT or at risk. This raises another issue because the nurses on the
units do not appear to have any formal way of knowing who is on ACCT or at
potential risk by having medication in their own possession. The toxicology
tests carried out following his death revealed an amount of paracetamol in
excess of the expected therapeutic dose. It was however below the amount
expected to be detected after a fatal overdose. The post mortem concluded
that hanging was the cause of the man’s death.
The evidence would suggest that the man took his life after he received a
solicitor’s letter initiating divorce proceedings. However, there are questions
about whether he had been storing medication with any immediate or longer
1 Assessment, Care in Custody and Teamwork (ACCT). The Prison Service’s
monitoring form and process for supporting prisoners at risk of harming themselves.
2 A Carer is a prisoner, much like ‘Listeners’ in public prisons, who is trained by
Samaritans and who offers support to other prisoners who are feeling vulnerable or
at risk. However, unlike Listeners, Carers are not bound by the Samaritan
confidentiality rules. On the First Night Centre all new prisoners are seen by a Carer.
Following this they can ask to speak to one whenever they feel the need.
4
term intention or whether they could genuinely have been for pain relief. It is
therefore difficult to know the exact trigger which led to him taking his life.
All those the investigators spoke to appeared to have formed the same
opinion of the man who died: that he was a polite, mature, easy to manage
prisoner. The general belief was that he had problems outside of prison but
was coping well within it. Even his cellmate thought that he had ‘perked up’
during the few days he knew him.
5
INVESTIGATION PROCESS
1. The principal investigator requested all the relevant records including
the man’s medical and core prison records. With her colleague the
principal investigator visited Altcourse to interview staff on several
occasions. One of the investigators also visited the prison to interview
healthcare staff alongside the clinical reviewer. Notices to staff and
prisoners were also sent to the prison to be displayed. In this instance,
no-one other than those identified by the investigation team raised any
concerns.
2. In all deaths in custody the police carry out an investigation of their
own. In line with a Memorandum of Understanding between the
Association of Chief Police Officers and my office, PPO investigations
can be progressed on an individual basis in consultation with the
police. A Detective Sergeant (DS) carried out the investigation on
behalf of the local Police. The DS met with the investigators on 16
June 2009 to discuss both investigations. In this instance, the
agreement was that the Ombudsman’s investigators could interview
staff after the police. This has inevitably caused some delay in the
completion and issuing of this report, particularly as no notification was
received from the police when they completed their investigation.
3. A clinical review into the man’s clinical care in prison was
commissioned and carried out by a clinical reviewer on behalf of the
local PCT. This was received on 20 November 2009. The clinical
reviewer was also delayed by the police enquiries.
4. HM Coroner for the local area was informed of my investigation and will
receive a copy of this report.
5. Two members of staff at Altcourse visited the man’s wife and son to tell
them of his death. Although the man had given his son’s details as
next of kin, it was agreed at the time that his wife would be contact
person. One of my Family Liaison Officers has been in contact with his
wife to offer her and her son the opportunity to be involved in this
investigation. They have not raised any questions for the investigation
but have asked to receive a copy of this report.
6. In September 2009, the man’s sister contacted the Ombudsman’s
office, having only recently found out about her brother’s death. She
explained that she and her parents had not been in contact with him for
several years but they wanted to be involved in the investigation and
for the following questions to be answered:
(cid:127) Why was he in prison custody?
(cid:127) How was he able to take his own life if he was being monitored?
6
(cid:127) Where was his cellmate at the time of his death?
(cid:127) Did he leave a note?
(cid:127) Why was he allowed to have a belt in his possession?
I have endeavoured to answer these questions within this report.
7
HMP ALTCOURSE
7. HMP Altcourse is a category B contracted out (privately run) prison for
remanded and sentenced adult males and young offenders. It is
managed by Group 4 Securicor (G4S) under contract to the National
Offender Management Service (NOMS). The prison opened in 1997
and currently holds up to 1,324 prisoners.
8. ‘Admissions’3 is the first area a prisoner arrives into whether he is
straight from court or transferring from another prison. At Altcourse the
number of prisoners passing through admissions ranges between 10 –
40 per day. Prisoners are initially seen by the admissions manager who
checks the warrant and personal details. They are then seen by other
admission officers who conduct a more in depth interview. Questions
asked include previous self harm history, suitability for cell sharing,
drugs problems and medical issues. Once the officers have completed
their reception process, all prisoners are seen by a nurse. If an ACCT
has been opened at any stage, this will be placed inside the file which
will accompany the prisoner wherever they go until the ACCT is closed.
9. At the time the man who died was in custody, prisoners were moved to
the First Night Centre (FNC) at the end of the admissions procedure to
ease the transition into prison and to provide extra monitoring
overnight. The next day they would move to the induction unit. This
has recently changed and now all first night prisoners go straight to
Furlong Green, which is the induction unit.
10. Melling unit is one of several residential units in the prison. Melling is
split into two wings, Melling Brown (1) and Melling Blue (2). The unit is
joined by a central office. Melling Blue is where the man moved to
after his time on Furlong Green. It holds between 85 – 94 prisoners
and is the ‘drug free’ and education unit. Prisoners on this unit are
expected to undertake voluntary drug tests and attend education.
Although drug abuse was not an issue for him, the unit is generally
more stable and quiet than other units and has a more mature
population. With the exception of prisoners who do not attend activity
for any reason, prisoners are unlocked for the majority of the day.
11. Healthcare services at the time of the man’s death, were provided by
Medacs Healthcare Group. Medacs describe themselves as a
healthcare staffing company providing recruitment expertise and
managed healthcare solutions to both the public and private sectors.
They were contracted to provide the healthcare services at Altcourse
and operated with one manager, two doctors and 32 nurses – including
registered and mental health nurses and healthcare assistants.
Healthcare is now provided in-house by G4S.
3 Also known as Reception
8
12. Canteen services at Altcourse are provided by Aramark. There is a
National Product List (NPL) which contains approximately 800 items.
Individual prisons then choose from this list to create a Local Product
List (LPL) which contains approximately 350 items. Paracetamol and
Lemsip have been available on the NPL, but Lemsip is now being
removed. The Department of Health’s Offender Health team are in
favour of paracetamol remaining available on the canteen list with the
following safeguards:
(cid:1) Local discussion should occur between the prison and
the healthcare provider as well as any other relevant
parties.
(cid:1) This should include a local risk assessment.
(cid:1) Agreement should be reached at the Partnership board
(cid:1) Audit, including clinical audit, should form part of
continued monitoring.
The maximum amount of paracetamol that prisoners can buy in one
week is one pack of 16 tablets. However, most prisons choose not to
allow paracetamol on their local list. Altcourse is one of those that
does not.
13. The last full inspection by Her Majesty’s Chief Inspector of Prisons was
in 2005. A short follow-up inspection was conducted in September
2007. The Chief Inspector found that Altcourse “… remained an
impressively respectful prison, with well maintained and clean
accommodation and very good staff-prisoner relations”. In her
summary, the Chief Inspector added that:
“… we have previously applauded the quantity and quality of
time out of cell for prisoners at Altcourse, which placed its
regime among the best of any local prison in England and
Wales. We were pleased to find that levels of purposeful
activity remained exceptionally good.”
14. In the 2007 inspection the Chief Inspector also noted that “mental
health provision was very good, with evidence of joint working between
primary and in-reach providers. All new prisoners underwent a mental
health assessment on admission…” Two years have passed since the
last inspection report so I do not go into more detail here. The full
report, and previous reports, can be found at
www.justice.gov.uk/inspectorates/hmi-prisons.
15. Every prison has an Independent Monitoring Board (IMB)4. The
investigators spoke with the Chairman of Altcourse IMB, when they
4 Each prison in England and Wales is monitored by an Independent Monitoring
Board (IMB), formed of volunteers from the local community. IMB members have
access to every prisoner and each part of the prison. The Board produces an annual
report.
9
visited the prison. They asked about the operation of the ACCT
process and Melling Blue. The IMB chairman said that, in his view, the
ACCT process worked well at Altcourse. He noted that there had been
concerns about attendance at case reviews and the management of
the personal officer scheme – which is also relevant to reviews. The
investigators were told that the prison was currently running a refresher
programme for staff and case managers to ensure the good quality of
ACCTs. He said Melling Blue was a good stable unit, which was run
well by professional unit managers. He confirmed that the man who
died had not made any contact with the IMB either verbal or written.
The IMB annual report can be found at www.imb.gov.uk.
16. The Ombudsman’s office has been involved in the investigation of 16
deaths in custody at Altcourse since April 2004 when I took over the
responsibility for all such investigations from the Prison Service. In the
year preceding the man’s death there were two deaths from natural
causes and three that were self inflicted. The only significant similarity
in my reports into those deaths and this one was the degree of
understanding of some healthcare staff about ACCT procedures. I
make a recommendation on this issue in this report.
10
KEY FINDINGS
17. The man who died was remanded into custody from court to HMP
Altcourse on 6 March 2009. The escort services had identified that he
was at risk of self harm/suicide and opened the appropriate form. This
was handed over with the Prisoner Escort Record (PER) by the escort
staff to the prison admissions staff. The Admissions Manager noted
the warning when he received the paperwork and highlighted it on the
PER form. In interview, he said that he spoke to the man who had told
him that, “if the chance arises he would attempt suicide”. The
Admissions Manager then opened an ACCT book, setting the
monitoring at five observations an hour. (Observations are set
depending on individual need and are regularly reviewed.) The ACCT
book would have followed the man to the next stages of his induction
and then onto the residential units for as long as it was open.
18. Officer W was one of the admissions officers on duty. He completed a
Cell Sharing Risk Assessment (CSRA) with the man. (All prisoners are
subject to a CSRA on admission to a closed prison. The CSRA
process is designed to assess the risks posed by an individual to other
prisoners.) He was deemed fit to share a cell but Officer W noted that
an ACCT book had been opened. In interview, Officer W said he
would have been with the man for 10 – 15 minutes. He could not
remember him specifically, because he sees a lot of prisoners every
day, but he did remember his name as he thought it was unusual. He
also remembered that it was the first time he had been in prison.
Officer W referred to the ACCT document in which he wrote: “low in
mood, poor eye contact, first time in prison”. After speaking with the
admissions officers, the man, as with all prisoners, was seen by a
member of healthcare.
19. During the admissions process, the man was interviewed by a member
of healthcare, Registered Mental Health (RMN) Nurse K. Nurse K was
responsible for the initial physical, mental and social screening
assessment. He noted that the man had previously received
medication for mental health problems and was receiving prescribed
medication: LOSEC Fluoxetine, an anti-depressant. As a result of his
medication, Nurse K referred him to the doctor and, because he was
on an ACCT, for an appointment with one of his mental health nurse
colleagues.
20. Nurse K completed his entries into the man’s medical record during
their consultation. The prison healthcare team use an electronic
recordkeeping system, System One. Many of the questions in the
initial screening are recorded by means of a drop down choice list. The
medical record notes that the man said “no” to the question of previous
self harm outside of prison. This was incorrect, but Nurse K said at
interview that they relied on the information given by the prisoner. Also
in the healthcare section of the CSRA, Nurse K ticked the “no” box for
the question “following the self harm assessment have any concerns
11
been raised?” The investigator queried why this was, given that Officer
W had noted in the section that an ACCT was already open. Nurse K
replied that he would not make any notes on the CSRA but would put it
in the ACCT book. There is no entry by any healthcare staff during the
admissions process on 6 March. The only mention is a record made
by operational staff that the man saw healthcare between 6.05 and
6.10pm. He also made an entry regarding the referral to another RMN
for “follow-up on ACCT” in the medical record.
21. After completing the admissions process, the man was moved to the
First Night Centre. Unit Manager M took the role of case manager for
the man’s ACCT document. Officer P completed the ACCT ‘immediate
action plan’, and then wrote that the man told her he did “… want to kill
himself but was not actively seeking methods and denied that he would
do it at present”. Officer P noted that he was in a shared cell and did
not appear to have any issues with his cellmate. He was made aware
of the telephone system (an agreed list of numbers that a prisoner
applies for in advance of being able to make phone calls), Samaritans
and Carers. She recommended five observations per hour.
22. The following day (7 March 2009), he was seen by a Carer. In the
interview he told the Carer he was unsure how he would cope in prison
as this was his first time. He was asked if he would like a follow up
interview with the Carers but answered “not now”. The interviewer
noted that he believed the man to have ‘first time nerves’, a history of
self harm and felt depressed.
23. Also on 7 March, Officer H completed the ACCT assessment interview.
The man told Officer H that he had been experiencing relationship
problems with his wife over the preceding few months. He said he had
been taking anti-depressants since November (I assume this means
2008). He told the officer he had taken an overdose and cut his arm a
couple of weeks previously hoping to “bleed to death”. He added that
he was upset that it had not been successful. He had been going to
hang himself the day he got arrested but was disturbed by the police.
He also said he had previously stabbed himself in the stomach and
groin, but it is not noted when this was.
24. Officer H described him as “very tearful” during the assessment and
“very low in mood”. He told her that he was comfortable with his
current cellmate and would like to remain with him. He added that he
was feeling ‘50/50’ and would not harm himself in custody, but would
when he was released. When asked about coping strategies and
reasons for living, he said that he did not know if his wife and son were
talking to him and “the only thing that would make him better was if the
problems with his wife disappeared”. He also expressed concern
about his dog, his job and getting someone to bring some belongings
to him. Officer H and the man agreed that he would see a counsellor.
Officer H explained about the Carers and Samaritans, which he again
declined.
12
25. Dr A saw the man the same day. The doctor noted that he was on an
ACCT and he had previously tried to stab himself. The doctor
prescribed him anti-depressants (Fluoxetine). He was then seen by a
nurse who cleaned and dressed his left arm. He told the nurse he had
cut his arm approximately two weeks previously. Neither contact was
recorded in the ACCT document other than to say he was “speaking
with doctor”.
26. The man was also assessed by Registered Mental Health Nurse
(RMN) D on 7 March. At interview, RMN D explained that the man had
been placed onto their list following the opening of his ACCT during
admissions. RMN D wrote in the medical notes that the man presented
as “… tearful and low in mood, he did maintain eye contact
throughout…” She added that he had told her his low mood was due
to being in prison and having problems with his wife, whom he had
hurt. He reiterated to RMN D that he would not harm himself in prison,
but would do so on release if he had not reconciled the issues with his
wife. RMN D offered the services of a counsellor, which he told her
prison staff had already done. She also told him he could see an RMN
again which he agreed to, and RMN D said she would see him again in
a week. (The follow up appointment did not happen. RMN D told the
investigation team that this was because she had been on sick
absence and when she returned it was on a shift pattern which led her
to work in Admissions. RMN D was of the view that her manager,
RMN N saw the man instead, but this was in fact over two weeks later.)
27. Later that day, the first ACCT case review was held. The man and Unit
Manager M were there and had the notes of a verbal handover from
Officer H. No member of healthcare attended. When the investigator
queried this, she was told that this was because the man’s needs at
that time were not clinical. The man repeated much of what he had
said to other members of staff. The ACCT remained open with the
observations reduced to three per hour with one meaningful
conversation with a member of staff in the morning and afternoon. A
Caremap (part of the ACCT process detailing action to be taken to
reduce the risk of self harm) was drawn up to try to help him. The
plans included counselling for his relationship problems, to see a carer,
clothes for his court appearance, and help to settle into prison. A
further review was scheduled for 9 March.
28. The observation log in the ACCT shows that he asked for his name to
go down for attendance at the chapel the following morning (8 March).
He told the officer he was feeling ‘fine’ and was happy to remain on the
first night centre for the weekend. (There was less need for spaces in
the FNC over the weekend. Prisoners were sometimes able to stay for
a bit longer than one night if the space was available.) He went to the
chapel at 8.55am the following morning. The observation log shows
that he was there for just over one hour. For the first 50 minutes it
notes that he “appears ok”. There is then an entry showing that he
13
talked to Ms C, chaplain and ACCT assessor, for approximately five
minutes. After this he was taken back to the FNC and was described
as being subdued and tearful.
29. Officer P spoke to him shortly afterwards at 10.25am. He told her he
had been tearful in church and that it all “came to a head”. The officer
felt that his mood seemed to have deteriorated which was due to not
having spoken to his family yet. He was going to try to telephone later.
He had arranged to go back to the chapel to have some time alone.
He also told the officer that he could speak to his cellmate with whom
he had developed a good rapport. He returned to the chapel in the
afternoon. Ms C told the investigator that she had a pastoral
conversation with him. She added that pastoral discussions are not
recorded, but she had made a brief note in his ACCT document. Ms C
said in interview that they had a lengthy and emotional conversation
and he had discussed feeling suicidal at times, mostly in the morning,
because he had “lost so much”. However, Ms C (who, as noted above,
is an ACCT assessor) did not have any concerns that there was an
increase in his risk of self harm or suicide. She told the investigator
that he seemed to be coping with prison and came across as a
capable, intelligent man. He had told her he was upset that he had
hurt his wife, but did not say he felt suicidal at the time and she had no
concerns that this was the case. Ms C noted the conversation in the
ACCT document and decided that she would check on him after a few
days to see how he was feeling.
30. During the following morning (9 March) Officer P spoke to him again.
She noted that he said he was feeling better than he had the previous
day but was still unable to contact his family as he had put the wrong
number down for the pin phones. He denied any current suicidal
thoughts. For the rest of the morning the observation log shows that
he generally spent it talking to his cellmate in their cell, until 1.50pm
when he transferred to Furlong Green (2) which is the Induction unit.
Mr S is one of the unit managers for Furlong and he took over as Case
Manager for the man’s ACCT book. A case review is documented at
2.25pm, although it is not clear if this was the start or finish time. The
review was a handover case review with Mr S, Unit Manager M and
Officer L. (Officer L no longer works for the prison, and therefore was
not interviewed.) The group discussed the man’s problems and
checked that the Caremap actions had taken place. The Caremap was
updated with actions about pin phone numbers, location and regime.
The man said he felt like “ending it all” so the ACCT remained open
with the current observations continuing. At interview, Mr S said that
the man had told him other prisoners thought he had been in prison
before because he was coping well for a “first timer”. This was a
comment echoed by other staff interviewed by the investigator. Mr S
explained that the man associated well and was a good prisoner on the
unit. It is his view that he was struggling to cope with issues outside of
prison, rather than within prison.
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31. As recommended in his Caremap, he had an appointment with the
counsellor, Ms F. Their first session took place in the afternoon of 9
March. There is very little information in the counsellor’s notes, and
during interview Ms F felt bound by her professional ethics and did not
want to say too much about the detail he shared with her.
32. Although the Ombudsman’s investigators have unfettered access to
information held in the prison, the investigator decided to continue
interviewing Ms F. They agreed that if there were questions which
remained unanswered, she would terminate the interview to speak with
Ms F’s community manager. In the event, Ms F answered the
investigator’s questions and the information she appeared to omit
related more to his offence and feelings about his relationship rather
than any suicidal ideation. Ms F had written in the observation log, and
discussed with the investigator, that he engaged well, that he said he
did not want to live if his relationship with his wife was over, but then
said he might want to live if he could keep his job. Ms F said that he
told her he would not take his life in prison as there were “too many
people around”. This contact was noted in the ACCT document but the
‘triggers’ section was not updated with information about his
relationship. Ms F and the man agreed to meet weekly for a six week
period. Later that evening he spoke with a Carer.
33. On 10 March, Officer L wrote in the ACCT observations that he had
spoken to the man who had told him he was feeling very low because
he had not had his medication yet that day. I have been unable to find
out why there was a delay. He also asked if he could try to contact his
solicitor again as he had not been able to get through the day before
(there is no log of any call made to his solicitor on the pin phone
record). He told Officer L that he had seen a Carer and found it helpful.
34. Later that day, the chaplain, Ms C, went to see him following their
conversation a few days earlier. He said that he did not feel suicidal or
have thoughts of self harm at the time. At interview, Ms C reiterated
that she had no more concerns about his safety. At 4.40pm, he went
to the officer’s console to ask about his evening medication – although
it is not clear what his concern was. An hour and a half later he told
one of the officers that he felt low because he still had not had his
medication. As before, I have not been able to find out what the delay
was. The following day the entries are more positive with the man
talking to staff about football and exercise. No issues or concerns were
raised.
35. When he was seen on the morning of 12 March, he told staff that he
had not slept well but was feeling better. He had an appointment with
his solicitor in the morning. He spent the rest of the morning watching
television, and associating on the landing until he went to education in
the afternoon. The ACCT case review set for 12 March took place in
the evening in advance of his court appearance on 13 March. Ms F
was unable to attend but Mr S, the man and an officer attended.
15
Because Ms F was not available, the group only conducted a mini
review before his court appearance. There is no evidence that a
written handover was given by Ms F or any of her colleagues, although
Ms F had written a note of her meeting with him in the ACCT book on 9
March.
36. The summary of the review shows that the man who died was more
relaxed than at the previous one: he was open in discussion and made
good eye contact. He was, however, apprehensive about his court
appearance and what would happen, saying that his solicitor had told
him he would return to prison. He told the meeting that he had “got his
head around that” and had no current thoughts of self harm because
his family were too important to him. He added that his apprehension
of prison had subsided and that he was settling and coping better. He
had been in contact with the Carers and was taking medication for
depression. The group discussed his progression from the induction
unit onto a main residential unit. Melling Blue (2) was the suggested
unit as it was a quieter, more stable wing with generally more mature
prisoners. He was able to stay on Furlong until a place became
available on his new unit. The observation levels on the ACCT
remained at three per hour with a conversation every morning,
afternoon and evening. The next review was scheduled for 16 March
and it was noted that Ms F should be invited.
37. The man attended Crown Court for a preliminary hearing on 13 March
and was remanded into custody to return to court on 1 May. He spoke
to prison staff about his court appearance. They recorded that he said
he felt “no better or worse” after court and that he had no issues being
back on Furlong Unit as he was settled there. He said he had no
thoughts of self harm at the time and the officer he was speaking to
thought that he seemed “happy”.
38. He received a letter from his son (although another document says it
was from his solicitor) on 15 March, with his son’s correct contact
details because the telephone number he had was incorrect. He
submitted an application for the number to be registered onto his
account so that he could make contact. He told an officer that it had
improved his day, and later that he was looking forward to being able to
talk to his son the following day (allowing time for the number to be
registered). He added that he had no thoughts of self harm at the time.
39. Ms F saw the man again on 16 March. In her notes, she wrote that his
problems concerned his relationship and he was fearful about losing
everything. In the ACCT document, Ms F wrote that he had engaged
well but talked about feeling depressed in the morning and if he woke
in the night. He told Ms F that he had “fleeting” thoughts of suicide
which depended on whether his marriage was over or not. He spoke to
Ms F about his plans to contact his son that day. Ms F said at
interview that he also joked with her about playing football and how he
16
was “getting too old for it”. She added that he seemed to be in high
spirits.
40. However, Ms F said she then spoke to Mr S and told him that, although
he was upbeat, he was still saying that he could not go on if he lost
everything. A clerk who overheard their conversation mentioned a
letter that the man had received. Ms F thought from memory (the
investigator has not had access to the letter) that it said “you have
made a right mess of it this time, you better pray for forgiveness”. The
writer added that praying had helped them during a difficult period. Ms
F believed that the letter was written to be supportive but was worried
he might not understand it properly. Mr S reassured her that the ACCT
would remain open. Again, the ‘triggers’ section of the ACCT
document was not updated.
41. Ms F was due to go on leave for a week. She told the man and
arranged to see him again on 26 March.
42. Later that day, he attended his ACCT case review with Mr S and an
officer. He told the group that he had not harmed himself since arriving
at Altcourse and had no current thoughts of self harm or suicide. He
said he needed to get more information from his son about what was
happening outside regarding his wife and their relationship. He
believed that his wife would ask for a divorce. He also said that he
might lose his job if he stayed in prison.
43. Arrangements were being made to move the man to Melling Blue. In
interview, Mr S said that this took some time because he could only
move once a space was available and Mr S had a few days off
pending. He wanted to arrange the move when he would be present
for the handover review. The man said he was coping with prison and
had played a football match that morning. He was trying to keep as
busy as possible to help him stop thinking about his problems outside.
In interview, Mr S said he believed the man’s problems were external
to the prison. In his view, the man did not give the impression that he
was struggling to cope with prison. His observation levels remained
unchanged and the next review was scheduled for 20 March.
44. The man who died made a telephone call5 to his son that afternoon (16
March). He asked his son to visit him and said that he was in “a mess”.
He wanted information about his wife and told his son that the marriage
was probably over. The next day the ACCT document shows two
entries by an officer who felt that he was “down”. He told one of the
officers that he felt most vulnerable to thinking of harming himself at
night time, but seemed to be controlling it and had no current thoughts.
5Telephone calls are recorded for random or specific monitoring. Not all telephone
calls would be routinely monitored by prison staff and there would have been no
reason to specifically monitor the man’s conversations. The recordings used by the
investigator were produced on request following his death and had not been listened
to previously.
17
(This differs to what he told Ms C about feeling most vulnerable in the
morning.) Later that day he telephoned his son. Again, he was mostly
concerned with what was happening outside and what his wife’s plans
were. He asked his son to arrange to visit him. He made a second
telephone call to his son that night. The conversation was similar to
the previous one and he asked for information about his wife, but his
son, who seemed to be in a difficult position, kept the information quite
general.
45. On 18 March, the man moved to Melling Blue (2). Because of the
move, Mr S and Mr D, Unit Manager on Melling Blue and new Case
Manager, brought forward the ACCT case review scheduled for 20
March. The two unit/case managers and the man who died attended
and discussed his move. There were no current issues outstanding in
his Caremap and arrangements were being made for his medication to
be transferred to the medical hatch on Melling Blue. He said he was
waiting for a visit from his son which he thought would be soon. The
group agreed that the counselling he was receiving would continue and
it was noted that Ms F should be invited to the next review, which was
set for 23 March. The investigator asked Mr S why no healthcare staff
were present at the case reviews. He said:
“I’ve made a conscious decision, right from the start, to
involve counsellors and not feel there was any overriding
physical need and he never mentioned any physical needs to
have anybody from healthcare there. Obviously he was on
anti-depressants and he was getting medicated for that. But
looking at it, that was a symptom to his problems and his
problems were being treated, they were being dealt with by a
counsellor, you understand what I’m sort of pointing at? … It
wasn’t the fact that he had a mental health problem where you
needed excessive involvement with RMNs, he’d been to the
counsellor to get at the root problems of his depression. So if
he’d been medicated to deal with the actual symptom of his
depression and the counsellors were dealing with the root
problems of it, so I didn’t feel as though there was any
overriding need to involve the RMNs at that point.”
46. Mr S added that healthcare do attend many case reviews but it is
based on individual need. He confirmed:
“We have an excellent relationship with healthcare and the
RMN team here and it is co-joined, it’s really good. And what
they do is if there are any specifics relating to SASH [suicide
and self harm] they do advise us of that. And obviously with
him being on an ACCT book, if they did have any concerns it
would be raised through the ACCT book when they’ve seen
him.”
18
47. Later that morning (18 March) at 11.50am, the unit officer’s
paracetamol log shows that he was given two paracetamol. There is
no record of this in his ACCT document. Later that day, he had his hair
cut. When staff spoke to him, he was cleaning his cell and appeared in
good spirits. He told Officer C that he was settled and had no issues or
concerns. He made no telephone calls that day.
48. The man’s new cellmate on Melling Blue was Mr A. At interview, Mr A
said that he was aware the man was being monitored on ACCT
procedures. He spoke to the man about prison and his court case and
Mr A told him that there were ways to start his life over again. Mr A
said he was a bit down, but seemed to perk up over the following days.
49. In the morning of 19 March at 7.50am, he approached the officers
console. He told staff that he needed to go to healthcare at 10.00am to
pick up some medication. He reiterated that he was settling onto the
unit but had a headache and was issued with two paracetamol by an
officer. The officer recorded this in the ACCT, adding that he made
good eye contact and there were no other issues raised.
50. Just over an hour later, Officer T spoke to him on the landing. He
complained of a headache but Officer T noted that he had taken
paracetamol less than four hours previously. The ACCT record shows
that at 10.45am he went to the healthcare centre but this is not entered
in his medical record. His medical record only makes an entry at
8.18am showing ‘surgery’, but gives no explanation and it is possible it
was to collect his anti-depressant medication.
51. At 1.55pm another officer spoke to him. The man who died said he
was getting on with his cellmate and had no thoughts of self harm. He
added that he had a migraine but had seen the nurse earlier and was
waiting to get some medication. (Again it is not clear in the evidence
available to the investigator whether he received this or not.) Later that
evening Officer C spoke to the man. He talked to her about
telephoning his son and was looking forward to a visit from him. He
had tried telephoning his son on seven occasions that evening but
there was no answer. He asked Officer C what courses were available
for him in prison, saying that it was his first time in prison and it was “a
lot different than he imagined”.
52. In the morning of 20 March, he told officers on the unit that he was due
to have a case review soon – but did not say when. He said again that
he was settled on Melling Blue and was getting on with his cellmate.
He added that he had no thoughts or feelings of self harm and would
like to come off the ACCT monitoring. The officer noted this, but he
continued to stay on ACCT until his case review. He telephoned his
son twice that day; both were short conversations. They centred much
around the previous calls and what was happening concerning his wife.
He said that he was “going to be stuck in here a long time” and had lost
his job. (It is not known how he knew he had lost his job or if he indeed
19
had.) He wanted his son to tell his wife that he just wanted to be out of
prison and would leave her alone if that was what she wanted. He
would not, as he phrased it, “come after her” because of his
imprisonment.
53. The man again asked his son to arrange a visit. Over the next few
days he carried on his routine and no concerns were raised. He went
to healthcare in the afternoon of 21 March to get medication. There is
no explanation but it is again possible that he was still waiting for his
anti-depressants to be transferred over to Melling Blue. He also saw
the nurse on the unit on the morning of 22 March but there is no further
information relating to the contact. Later that day, during one of the
observation conversations, he spoke about his forthcoming review and
that he hoped to come off the ACCT monitoring. Again he said that he
had no issues and maintained good eye contact and body language.
He made a telephone call to his son; this was much the same as
before but there was also mention of a friend visiting him the following
Tuesday (24 March). The next day he rang his son again. The
conversation revolved around his wife and her plans. He told his son
that some other prisoners had said he would get two years
imprisonment. He felt that it was wrong that he was in prison. His son
said that he could not get through on the visits booking line but would
try again.
54. At 11.45am on 23 March the paracetamol log shows that the man was
issued with two paracetamol by Officer C. This action was not logged
in the ACCT. At 2.30pm, he had another ACCT case review. Mr D,
Officer K, and RMN N were in attendance. Mr D wrote in the log that
the man was positive in the review, and that he said he had settled on
to Melling Blue, was doing full time education (numeracy and art) and
that the bulk of his day was spent purposefully. The group discussed
the impending court case. He said he would not be contacting his wife
but expected to see his son. RMN N explained to the meeting details
of his medication. In interview, he said that this referred to his
explanation to the man about the effects of stopping the medication
and the need to take it consistently. Mr D wrote that the man gave no
negative indicators and that his body language and eye contact was
good. Everyone was in agreement that the ACCT book should be
closed and this was done.
55. In interview, Mr A said that the man enjoyed a laugh and joke with him
and other prisoners, so much so on one occasion that one officer had
gone into the cell and said (good humouredly), “have you three
forgotten you are in jail”. Mr A thinks this was on the Sunday – the day
before the ACCT was closed.
56. A post closure ACCT review date was not entered into the record of the
review. (They are usually held within seven days of the ACCT closing.)
Although it is unlikely a review would have taken place prior to his
death, the investigators questioned why it had not been set. Mr D
20
explained that it was an oversight. He said he would have checked his
diary first and would probably have written it there, but had not got
round to writing it into the ACCT document.
57. That evening (23 March), the man called his son. Their conversation
again lasted only for a few minutes. As before, he wanted to know
what his wife was doing and told his son that it was up to her to get him
out of prison. His son told him that one of his friends was due to visit
the following day. He had not seen his name on the visits board so
was not aware. He thought he might be able to give the friend’s
address as somewhere to live and could apply for bail. He said he
would call his son the following evening. He tried on four occasions,
but got no answer.
58. The man received a letter from his wife’s solicitors on 24 March.
(Although correspondence is not logged at Altcourse, the letter was
written on 23 March and, as prisoners receive their post in the
afternoon, it is safe to assume that he received the letter on 24 March.)
It is likely that the letter would have arrived under Rule 396. The letter
notified him that his wife wanted to pursue divorce proceedings and
enclosed a copy of the divorce petition that had been lodged with the
court on 23 March.
59. That evening the man had a visit with a friend. Two people were due
to visit, but only one attended. It appears that this was the person he
had hoped would give him a bail address. The details of the visit are
not known to staff, but when the investigators spoke to his cellmate, Mr
A, he said that he thought the man had been expecting his son. Mr A
thought the man was a bit down, and he went to sleep early saying that
he had a headache. No concerns were raised to staff either by the
visitor or the man.
60. Mr A said that, on the morning of 25 March, the man who died woke up
and had a cup of tea. He then went to the officers console to get an
application form because his friend had brought some property for him.
None of the staff asked by the investigators could remember the
request. He told Mr A that he had a migraine and would not be
attending education. Mr A said he had complained of migraines before
so it did not cause any alarms for him.
61. His medical record shows an entry at 9.25am by Nurse B. (This entry
would have been made after the nurse had dispensed medication and
returned to healthcare to complete the prisoner records and her contact
with him is likely to have been nearer 8.00 – 8.30am.) Nurse B
recorded that he was given medication for “cold symptoms/sore throat”.
She said in interview that he came up to the hatch and, when she
asked how he was, he replied “I’m fine”. Nurse B described him as
6Rule 39 is used for post which is confidential because of legal privilege. Staff are not
permitted to read the contents.
21
looking as if he had flu symptoms and that he appeared “flushed”. She
added that he told her he wanted “something for my throat, my bones
are aching”. As well as re-ordering his anti-depressant medication, he
was given a 12 tablet pack of 200mg Ibuprofen “given for pain” and a
two day supply of paracetamol “given for pain/high temp” (16 tablets).
62. Nurse B explained that she would put the person’s name and date on
the box so that subsequent prescriptions could be monitored. The
details would also be written in a book and then added to the medical
record after dispensing was finished. She added that she would also
let the officers know so that they would not issue any paracetamol.
There is no evidence that this happened on 25 March in respect of the
man. The investigators asked whether Nurse B would know if
somebody was at risk, for example on an ACCT document. Nurse B
said that she would not know unless she had been involved with them
before. She added that information was sometimes shared between
the nurses and officers, but there was no formal standardised system.
63. The officers on duty on Melling Blue that day were Officer T, Officer C,
Officer R and Officer U. Officer U is usually assigned to Melling Brown
(1), but his colleagues on Melling Blue that morning were all relatively
new staff and he was asked to help out as he was more experienced.
64. Mr A was preparing to go to education between 9.10 and 9.15 am and,
while he was waiting, spoke to Officer C. He said in interview that he
asked the officer to keep an eye on the man who died as he had a
migraine and did not want to go to education. Mr A then told Ms X,
Education Instructor, that the man would not be attending that day. Ms
X said that she told Mr A to inform the officers although this was not
confirmed by Mr A. Officer C said Mr A had not raised it with her as
specific concern over suicide, but had mentioned it as part of a
conversation which she felt was just ‘chat’ before he went to education.
She remembers, however, walking past the man’s cell shortly after she
started her cell checks. She did not speak to him but remembers him
sitting on his bed.
65. Education registration is between 9.00am and 9.15am. A list of those
in attendance is passed to officers who then check to see why any
prisoners have not attended. Shortly after registration, at
approximately 9.20am, Mr A went into the classroom. He realised that
there were no pens so went back to his cell to get some. He had to
use his key to unlock the door. He assumed that the man who died
had locked the door because of his migraine. The curtains were also
closed. He told the investigators that the man was standing between
the bed and the sink. They passed comment on the lack of pens in
education and Mr A left the cell again. He then recalls all the prisoners
being told to go into their cells approximately ten minutes later.
22
66. At approximately 9.30am, Officer T started to go round to check those
who were not on the register. The man’s cell is one of the first next to
the officers console. In interview, Officer T described finding the man
as follows:
“I went into the cell at first, I just like opened the door and just
looked in and he wasn’t there and I turned around and just
checked that because sometimes the teachers miss, but the
cell’s right by the education block. So I just turned around and
just double-checked that they hadn’t missed him off because I
knew it just wasn’t like him at all. And then I shouted his name
because that’s what, if you can’t find them you shout them,
shouted his name and then, I don’t know if something, I believe
something told me to go back in the cell, but I’m not sure. And I
just went back in and I lifted the bed covers up just to see in
case I hadn’t seen him and the toilet door was left slung back
open. And I just stepped back and moved it and seen him
hanging ...”
67. Officer T shouted for her colleague Officer R and called a ‘Code 1’7
over her radio. Officer R was on the landing above as was Officer C.
He quickly responded to Officer T’s call. When he arrived Officer T
lifted the man to take the weight from the ligature, which was found to
be a belt tied to his cupboard door. Officer R used his anti-ligature
knife8 to cut the belt and the officers lay him flat on the ground. Officer
C, who had not initially realised the urgency of the call for assistance,
was also in the cell by this point and tried unsuccessfully to find his
pulse.
68. Officer O who works on Melling Brown, the unit next to Melling Blue
with a shared office in the middle, was in the office when she heard the
Code 1. She quickly went to the cell – approximately ten to twelve
metres from the office – and saw the man on the floor. He was “blue in
colour”. At the same time, Officer U, who had been on the top landing
in Melling Blue, arrived at the cell.
69. Officers U and O started cardio pulmonary resuscitation (CPR) until
healthcare staff arrived to take over. In the meantime, all other
prisoners on the unit were locked into their cells. The Unit Manager,
Mr G, had also responded to the call for assistance. It was his role to
direct and support staff and generally control the area.
70. CCTV shows some nurses entering the wing with what looks to be an
emergency equipment bag at 9.32am. They checked his vital
7Code 1 is an emergency code sent across the radio calling for staff and medical assistance.
It is commonly used in the event of a prisoner being found hanging.
8 Aknife designed make the cutting of a ligature easier. It is shaped like a fish and is
sometimes known as a fish knife.
23
observations (pulse, breathing, temperature) but got no response. One
of the nurses called for paramedics and then attached the defibrillator9.
There is some discrepancy in the documents about the arrival time of
the paramedics. The communications room log records that an
ambulance was called at 9.40am and that the ambulance arrived at the
gate at 9.45am. According to the CCTV, a first response paramedic
arrived outside Melling Blue at 9.40am. The paramedics took over the
resuscitation attempts. The CCTV shows an ambulance crew arriving
at 9.48am although the crew did not enter the unit for a couple of
minutes. It may be that the communications officers have not entered
the arrival of the first response paramedic and the correct time for the
call, or it may be that the CCTV clock was wrong on the day.
71. The emergency services tried to resuscitate the man out on the landing
for seven or eight minutes before he was put on a stretcher and taken
to the ambulance. From the CCTV, it looks as if the paramedics
continued to carry out chest compressions while he was being taken
out on the stretcher. He was then taken to hospital in the ambulance.
When he arrived at the hospital a doctor pronounced his death. This is
recorded at 10.30am on 25 March 2009.
Events after the man’s death
72. The prison’s Family Liaison Officer, Ms E, and the prison chaplain, Mr
R, were the members of staff who went to tell the man’s son, who was
recorded as his next of kin, and his wife about his death. They had
been in contact with the police local to the man’s home address and
went to meet the police officer who had arrested him. As the family
were known to her, the police officer accompanied Ms E and Mr R to
the man’s home address. His wife was at home but his son was out.
The staff asked her to contact her son at which point she asked if she
was going to be told that the man was dead. Ms E confirmed this and
gave some brief details. His wife then contacted her son and asked
him to come home. When he arrived, the prison staff explained what
had happened. They also discussed practical matters such as help
towards the funeral costs and a visit to the prison if the family wished.
73. Staff involved in finding and attempting to save the man attended a ‘hot
debrief’ in line with prison contingency plans. (This gives staff the
opportunity to talk through what had happened as a means of support
and to identify any issues or learning points.) The minutes of the
debrief show that staff felt the incident had been managed as well as
9 Adefibrillator can restart the heart in some cases by giving an electric shock. It detects the
electrical activity in the heart and gives automated instructions to the user.
24
was possible, and that good communication was evident. Staff to
whom the investigators have spoken all felt they were given adequate
support and knew where to ask if they needed any more.
74. In line with policy, the man’s cell was secured following his death until
the police arrived. The police found a note in the pocket of one of his
items of clothing. It is not certain if this was intended as a suicide note
and it is undated. It says “good buy [sic]” twice. It also says, “I wish I
cuad [sic] go back in time so you cuad love me again. I love you so
[wife’s name] baby.” It then adds, “she did this, I love her so much
[wife’s name]”.
75. A post mortem was carried out. The toxicologist found high levels of
paracetamol in the man’s system. There was also Ibuprofen, which
was found to be within a therapeutic dose. The following extract is
from the toxicology report:
“The comments and interpretations that follow are based on the
reading of scientific and medical literature, and should be
viewed as general comments only. In addition, it is not possible
to determine from measurements on a single blood sample
precisely when a drug was consumed, nor the exact dose
consumed.
“Paracetamol – … in the case of the man, the concentration of
paracetamol detected in the blood is high and significantly in
excess of the concentration I would expect to detect after the
normal therapeutic use of this drug. It is possible that the use of
such a large amount of paracetamol could have produced
observable damage to the liver. It should also be noted that if a
significant number of hours had passed between the ingestion of
paracetamol and his demise the paracetamol concentration may
have been greater than that detected since paracetamol is
relatively rapidly eliminated from the body.”
The toxicologist explained changes in the body following death and
commented that due to these changes:
“… it is not possible to estimate the actual drug concentration at
the time of death. Therefore, it should be noted that I cannot
exclude the possibility that the post-mortem paracetamol blood
concentration found may not be representative of the circulating
levels at the time of death due to the post-mortem redistribution
of the drug … In the case of the man it should therefore be
noted that I am unable to rule out the possibility that the
elevated paracetamol concentration detected above may be due
to post-mortem redistribution.”
In respect of Ibuprofen the toxicologist commented:
25
“… the concentration of ibuprofen in the blood sample is within
the range of concentration detected after the therapeutic use of
this drug. Therefore I would not expect this drug to have been
capable of exerting any adverse effects on the man immediately
prior to his death and hence shall not be considered further.”
In conclusion the toxicologist wrote:
“Paracetamol was detected in the blood sample at a high
concentration, in excess of the concentration I would expect to
detect after the normal therapeutic use of this drug, but below
the concentration I would expect to detect after a fatal
paracetamol overdose. This finding suggests the possibility of a
relatively recent paracetamol overdose.
“The analyses were negative for alcohol, commonly
encountered drugs of abuse, prescription and non-prescription
drugs (other than paracetamol and ibuprofen), this rules out the
possibility that he was affected by these substances at the time
of his demise.”
76. Following the toxicology results, the police searched the man’s cell and
removed the following:
(cid:1) An empty box of Paracetamol (dated 23.03.09)
(cid:1) An empty box of Ibuprofen – 12 pack (dated 23.03.09)
(cid:1) A box of Omeprazole 20 mg – 10 pack, 3 remaining
(cid:1) An empty box of Ibuprofen – 12 pack (dated 23.02.09 but
prescribed to another prisoner)
(Regarding the first two findings, the investigator had asked the police
and coroner’s officer for confirmation of the date dispensed as other
evidence suggests it was issued on 25 March. No confirmation has
been received and thus I make the assumption that it was a typing
error in the police notes.)
77. When the investigators spoke to Mr A he said it was a shock as he had
seen the man ten minutes earlier. He said, in his view, the man had
perked up but that perhaps this was just a front he had put on. He
reiterated that he might have had some bad news at his visit the night
before. Mr A was not sure, but he had seemed fine the next morning.
He said that even in hindsight he would not have expected him to take
his life. For instance, he did not think that someone picking up an
application to bring property in would be thinking about taking their life.
Mr A said that the man was ‘getting on with it’ (meaning prison), playing
pool, mixing with other prisoners and did not keep going to officers and
asking for things. In Mr A’s view there was no indication that he was
not coping.
26
78. Mr A also told the investigators that on one occasion when the man
was on an open ACCT he asked a nurse for medication and they gave
him a whole box. Mr A did not confirm what the medication was or
when it happened, but it was likely to be Paracetamol or Ibuprofen. He
said that he went to one of the officers and said, “you know he’s on
watch and they’ve given him a whole box …” and the officers went and
removed it. (There is no recorded information to confirm this and I
simply report what Mr A has told the investigators.)
27
ISSUES CONSIDERED
Clinical care
Admissions
79. Nurse K completed the man’s cell sharing risk assessment after the
admissions officers. He did not give further information regarding his
risk of self harm on the CSRA. He qualified this in his interview by
saying he would write it in the ACCT and in the medical record. There
is no record of the man’s contact with Nurse K in the ACCT document
and non-healthcare staff would not have access to his medical record.
Whilst I do not suggest that this omission contributed in any way to his
death, it was not good practice.
80. If somebody is at risk of self harm and this is known at the time of
completing the CSRA, it should be recorded. The ACCT document,
once closed, would be filed away, and the medical record is not seen
by officers. In contrast, the CSRA is kept in a prisoner’s wing history
sheet and is therefore more accessible to all staff. The CSRA is there
for a reason and all relevant information should be logged within it.
81. Additionally, the doctor and nurse both saw him on 7 March but neither
made any entry in the ACCT document.
The Head of Healthcare should ensure that all healthcare
professionals are aware of the ACCT process and recording
systems. It might be necessary to have refresher training
specifically targeted at healthcare professionals.
Communication
82. Because he had been placed on an ACCT, the man was referred to
and seen by a mental health nurse, RMN D, following his admission to
prison. This was good practice. However, RMN D was then away from
work with sick absence and, following her return, worked in a different
area of the prison. In interview, RMN D was of the opinion that the
man was seen by her colleague instead, but this was over two weeks
later and only because he had been asked to attend an ACCT case
review.
83. It was explained to the investigators during the interview with RMN N
that the nurses are individual practitioners with their own caseloads. It
became clear that if a particular RMN could not carry out their follow-up
appointments their colleagues would be unaware, and it would fall to
the prisoner to highlight any missed appointments. I believe that the
duty of care should lie with medical staff. Prisoners accessing RMN
support or who are on an ACCT might not be fit or well enough to
pursue this service.
28
84. The clinical reviewer has found that the man was “lost” by healthcare
following his initial assessments by the doctor and RMN. There
appears to have been a lack of communication between the RMN team
in this instance, and I agree with the clinical reviewer’s view that a
system needs to be put in place to ensure that workload is handed over
if one of the team is absent for any reason.
The Head of Healthcare should implement an auditable system to
ensure that caseloads from the mental health team are handed
over when any staff are absent.
85. Another area highlighted to the investigators concerns information
sharing by the counsellors. In interview, Ms F was reluctant to talk
about her contact with the man for fear of breaching confidentiality. It
became apparent also in RMN N’s interview that counsellors do not log
their contact in a prisoner’s medical record. This again leaves the
potential for omissions in treatment and care if a counsellor is
unavailable or absent from work. For example, when RMN N attended
the man’s case review on 23 March he only had the history written by
RMN D. He did not have access to contact records with Ms F. Given
that Ms F was on leave, it would have been very useful to others to
have had a note of her concerns. Ms F had not seen the man since
her last verbal handover to operational staff prior to his ACCT review
on 16 March. This was by chance rather than design. I do not believe
the lack of written record contributed to his death, but it would have
given RMN N more information to work with. It might also be important
in situations for other prisoners in the future.
86. I appreciate that healthcare have a duty to maintain patient
confidentiality, but the issue of ‘medical in confidence’ should not used
as justification for not sharing information or completing ACCT
documents as required. As before, I do not suggest that this
contributed to the man’s death because he was monitored closely and
his contact with healthcare was minimal. However, on at least one
occasion a member of operational staff did not invite healthcare to a
case review because she did not consider his needs to be clinical.
87. There is guidance by both the Prison Service and the NHS on the
sharing of medical information. Particularly relevant is Prison Service
Order (PSO) 2700, the full version of which, including reference to
other guidance, can be found on the Prison Service website. The PSO
is quite clear about the responsibility of healthcare staff at paragraph
1.11:
“Prisoner safety and well-being means that managers need to
be trained to ACCT Case Manager level (as they are likely to
need to undertake these duties), and all staff in contact with
prisoners need to be aware of and trained to ACCT foundation
level. Therefore it is important that Healthcare Managers –
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through their Partnership Board – make every effort to ensure
the local training strategy reflects this in respect of all healthcare
staff (agency wherever possible and permanent employees,
whether existing or new) and mental health in-reach teams.
“Healthcare Managers must ensure all healthcare staff (as
above) are aware of the importance of sharing risk and care
information with staff from other disciplines, are informed that
this does not contradict professional guidelines, and do share
such information with those managing individual prisoners.”
The Head of Healthcare and Safer Custody Co-ordinator should
work together to ensure that healthcare professionals are fully
aware of their duty and role in the ACCT process. This might be
incorporated into the training recommended above.
Medacs should have in place a Service Level Agreement with all
external agencies, including the counselling service, contracted
to carry out services through them to ensure effective team work.
The Director of Altcourse should be satisfied that all contracted
agencies share information effectively.
Medication management
88. The man who died was prescribed an anti-depressant whilst in
custody. This was not to be held in his possession although there was
no risk assessment in the documentation provided to the investigators.
The clinical reviewer also found that there were discrepancies in the
understanding of who should carry out a risk assessment and, indeed,
if one was carried out at all. Although there was no other evidence to
support it, his cellmate told the investigators that the man had been
given medication in-possession whilst on the ACCT but that the officers
removed it after he alerted them. All prisoners should have a risk
assessment for in-possession medication and this should certainly be
the case for prisoners on an open ACCT.
The Head of Healthcare should ensure that the in-possession
medication risk assessment procedures are clear to all staff and
are carried out appropriately. The Director should ensure this
also forms part of the cell searching procedures.
89. There do not appear to have been any issues regarding collecting
medication prior to the man’s move to Melling Blue. However,
thereafter there are several entries in his ACCT document about
‘waiting for’ or going to healthcare for his medication. None of the staff
interviewed could give an explanation, and I can only assume that it
took longer than normal for the prescription to be transferred between
the two units where he lived.
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90. In the week prior to his death, the man requested paracetamol from the
officers on the wing. Current practice at Altcourse allows officers to
give a prisoner two paracetamol twice a day. This is logged in a book
at the officers desk. The day that he died, he asked for and received
paracetamol and ibuprofen from the nurse on duty, Nurse B which he
was given in-possession.
91. This practice presents two issues. First, although Nurse B said that
she would check the officer’s log, this did not appear to happen and is
not necessarily something all healthcare staff would do. There was
also no transfer of the information from the officer’s log into his medical
record. This means that he, or any other prisoner in the same
situation, could have had access to more than the allowed limit of
paracetamol by asking both an officer and nurse separately. For
prisoners on ACCT this is especially risky, particularly when there is no
risk assessment for in-possession medication.
92. Secondly, Nurse B said in interview that she would not necessarily
have been aware that he was on, or had been on, an open ACCT. The
current system seems to rely on informal communication between
officers and nurses on the wing. Again, this leaves a vulnerable gap in
which prisoners can access medication inappropriately.
93. I have considered the fact that paracetamol is on the approved list for
canteen shopping (even though this is not authorised at Altcourse),
before being critical of the practices mentioned above. However, a
maximum of 16 tablets a week is the authorised amount on the
National Product List. The system at Altcourse allows for a nurse to
issue 16 tablets as a two day course. If the prisoner is then allowed to
get more paracetamol from officers without this being checked by
healthcare professionals, he can end up with more than the
recommended limit within a short space of time. The toxicologist found
high levels of paracetamol in his system and, although not a lethal
quantity, an amount possibly leading to an overdose. I strongly
recommend that the practices surrounding the dispensing of
medication are reviewed. It would be good practice to include the
Safer Custody Co-ordinator in discussions around ACCT and over the
counter pain relief.
The Head of Healthcare and the Pharmacist should review the
medicine management policy in relation to over the counter
medication to ensure that potentially unsafe practices cease.
This should include:
(cid:127) a system to ensure that healthcare professionals
know which prisoners are on ACCT or at risk
(cid:127) a system for ensuring nurses and officers do not
give out more than safe amounts of over the counter
medication.
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Record keeping
94. In the nearly six years that the Ombudsman’s office has been
investigating deaths in custody, I have had frequent cause to criticise
handwritten records. However, in this instance it is the electronic
records which give rise to the clinical reviewer’s recommendation,
which I endorse.
95. The clinical reviewer has found that the electronic recording system
used by Medacs at Altcourse (System One) was difficult to follow and
had numerous meaningless entries for example ‘surgery’ but with no
further explanation. There were also omissions in the records. On two
occasions the man missed or was delayed in receiving medication but
the reasons were not recorded and there are no follow-up prompts.
96. When the ACCT was closed on 23 March, there was no entry in the
medical record. I have already mentioned that the counsellors do not
record their contact in the medical record.
Medacs should review System One to ensure that it is fit for
purpose taking into account the comments above.
The Head of Healthcare should instruct all healthcare staff,
including counsellors, to log all contact with prisoners to ensure
continuity of care.
Assessment, Care in Custody and Teamwork
97. Some of the man’s family have questioned why his ACCT monitoring
came to an end. I hope that the key findings demonstrate the
reasoning and the decision made by staff. PSO 2700 advises that:
“The ACCT Plan can only be closed once all the CAREMAP
actions have been completed and the Case Review Team
judges that it is safe to do so, i.e. that the problems that caused
the ACCT Plan to be opened have been resolved or reduced,
the prisoner is able to cope with any remaining difficulties, they
have access to and are making use of at least some positives,
e.g. friends, family, counsellor, member of chaplaincy team,
hobbies, education/employment, and they know who to contact
(and how) should they need support in the future.”
98. The actions in the man’s Caremap were generally practical issues
involving settling into prison. All the issues had been actioned. Some
staff were aware that he was having problems outside prison, but he
presented as someone who was coping with prison. He had access to
and had been in contact with a counsellor, the chaplaincy team, and
the Carers, and he was receiving anti-depressant medication. Support
from officers was also available. He was engaged in full time
32
education and spent his time purposefully. He also had some contact
with the mental health team, albeit that there was an oversight with the
follow up appointment.
99. The clinical reviewer has made a recommendation that the National
Offender Management Service (NOMS) consider having a named RMN
for every prisoner on an open ACCT. I appreciate that this might not
always be feasible. It is a concern, however, that a member of
healthcare was not routinely invited to the case reviews, although I
understand the logic that the man was under the supervision of a
counsellor and did not present with any physical health problems. That
said, I have already indicated the clinical reviewer’s view was that he
was ‘lost’ by healthcare.
100. Mr S said in interview that there was good joined up working between
healthcare and the officers with regards to the ACCT process. I think
that this good working relationship should be utilised more fully.
Involving a member of healthcare at all case reviews means they can
both contribute medical information unknown to operational staff and
also take information away to better inform the rest of the healthcare
team. For example, the use of paracetamol could be better monitored.
101. I believe that to ensure no information is missed a member of
healthcare should always be invited to attend case reviews. That said,
it will only work efficiently if information is shared within the healthcare
agencies themselves. This re-enforces the need for the counselling
service to be more formally involved with the healthcare department.
The Director and Head of Healthcare should ensure that a member
of healthcare is invited to attend all ACCT case reviews.
102. One of the man’s sister’s questions was how he was able to have
access to a belt given that he had been on an ACCT. The following is
an extract from the guidance on the removal of personal items from
prisoners. (Full details can be found in Chapter 8 of PSO 2700 on the
Prison Service website.)
“… previous methods of self-harm can be a good indicator of
likely risk. Cigarette lighters, matches and flammable materials
should also be considered for removal where the individual has
a history of self-burning, arson or self-harm by smoke inhalation,
as should medication, both that belonging to the individual and
to a cellmate, and (particularly for women) plastic bags.
“However, removing personal belongings from a person who is
feeling hopeless and depressed (especially items of clothing,
belts or shoelaces) can increase feelings of distress and
therefore increase the risk of suicide, self-harm or a higher risk
method of self-harm. Fear of losing their normal possessions
can discourage prisoners from disclosing suicidal feelings. And
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removal of some items in possession (such as pens) can
deprive the individual of access to creative activities which might
distract them from their painful feelings. Where possible,
prisoners at risk should be allowed to retain their belongings
unless it is clearly unsafe to do so.”
103. Additionally, the PSO refers to prisoners who have items removed
being ‘singled out’ or teased by other prisoners which is something that
staff need to take into consideration.
104. Sadly, prisoners can find all manner of materials to use as ligatures or
implements of self harm should they choose. For example, bedsheets
or clothing are readily available. With regard to previous methods
used, the man is recorded as stabbing himself on one occasion and
tying a noose in another. In these circumstances, it would have been
disproportionate for staff to have removed all items from his
possession. Moreover, even if staff had deemed it necessary to
remove his belt for all or part of the time he was on an ACCT, this
would have been returned to him when the ACCT was closed.
Legal correspondence
105. The day before he died, the man received notification that his wife was
seeking a divorce. This was something that he had feared, but he was
working with the counsellor on the subject. The letter arrived from his
wife’s solicitors who were based out of the local area. Correspondence
from legal services is not monitored by staff as it is confidential.
Although the investigator did not have the envelope in which the letter
arrived, it is reasonable to assume this correspondence was processed
under Rule 39. This would mean that, unless he had told someone, no
staff or prisoners would be aware that he had received the letter.
There is no evidence to suggest that he did tell anybody.
106. The only other way that staff could be made aware of these situations
is if the legal representative or a concerned family member or friend
notifies them. In this instance the prison did not receive any such
information. At Altcourse, a notice is displayed in the domestic and
official visits areas for all visitors, including legal staff, asking them to
make staff aware of any news or information which might cause a
prisoner distress. In this instance, the letter arrived from out of area
and therefore the firm sending it would not necessarily be familiar with
Altcourse’s procedures or notices.
107. The clinical reviewer has recommended that the prison needs to further
explore strategies by which it could be forewarned of any bad news
letters arriving from solicitors. I feel that Altcourse already try to reduce
the risk of this happening so do not make a recommendation to the
prison directly. Unfortunately, the size of the prison population means
34
that many prisoners are out of their or their family’s local area. This
means that there is a gap where solicitors, friends or family are not
familiar with the processes and procedures of the prison.
108. This is something I have reported on in other investigations. I am
aware that the Safer Custody and Offender Policy group within NOMS
have approached the Law Society to ask them to issue guidance to all
their members. However my understanding is that the Law Society has
not agreed to any formal action. I would urge NOMS to approach the
Law Society again.
NOMS should approach the Law Society seeking their agreement
to issue guidance to all solicitors to notify prisons directly if they
are delivering difficult or distressing information to a prisoner.
Family comments following receipt of the draft report
109. The man’s wife said in her response to reading the draft report
that although, divorce proceedings were underway she did not know,
until reading the report, that any papers had actually been served on
the man. She added that she had been told by her solicitors, following
her husband’s death, that the proceedings had been stopped and no
papers served. She did not receive any paperwork relating to the
divorce when his property was returned. This might be because the
police had taken them from his cell. It was her understanding that her
husband was aware she was filing for divorce and said that when their
mutual friend had visited him the day before he died, he had spoken to
him about it. She has also said that amongst the paperwork which was
returned with his property was an instruction to his defence solicitor not
to contest any of her evidence. She hopes that it will be acknowledged
in the wider context of his death that the catalyst for the divorce was
her husband’s offence against her.
110. The man’s sister did not find out about his death until September
2009, she contacted the prison but was unable to get a response from
them. The investigator let the prison know about his sister’s
involvement in the investigation, however the prison dealt only with his
registered next of kin - his son and also with his wife. Although the
prison decided not to liaise with his sister at that time, it would have
been courteous to return her initial call and explain their reasoning. The
relevant PSO indicates that it is not uncommon for liaison to be
necessary with more than one person in a family. The prison has since
agreed that his sister can contact the Head of Safer Custody at the
prison and his contacts details were forwarded to them in January
2010.
111. The man’s sister still believes that his post should have been
monitored more closely. I have explained the process for Rule 39 post
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above. It would not be reasonable, or practical, to expect wing staff to
be aware of all the Rule 39 mail being passed to prisoners. It may well
be handed out by an officer who is not regular to the wing or another
member of staff who is only delivering the mail and would not be
familiar with the prisoners on the wing. His ACCT was closed, the
reasons for which I have explored earlier in the report and remain
satisfied with. By closing the ACCT staff believed he did not need any
additional support. The only way staff could reasonably know that he
had received a solicitor’s letter and that he potentially found the
contents distressing would be if he told them. He did not do this nor
did he tell his cell mate.
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CONCLUSION
112. When the man who died arrived in prison, concerns had already been
raised about his self-harming behaviour. He was monitored under
ACCT procedures for nearly three weeks. During this time he had
extensive support from wing staff, the chaplain, a counsellor, Carers,
and is said to have felt able to speak to his cellmate about any
concerns.
113. Whilst being monitored on the ACCT, the man did not harm himself.
All those to whom the investigators spoke appeared to have the same
opinion that he was a polite, mature, easy to manage prisoner. The
general belief was that he had problems outside of prison but was
coping well within it. Even his cellmate thought that he had ‘perked up’
during the few days he knew him. The man said on several occasions
that he would not harm himself in prison.
114. Regular ACCT reviews were held and, although they could and should
have involved a better cross-section of staff, the likelihood is that the
ACCT would still have been closed on 23 March. In hindsight, it would
be easy to argue that it should not have been closed. However I am
satisfied that with the information and knowledge staff had at the time,
and given his positive behaviour, the ACCT was closed appropriately.
115. He received a letter initiating divorce proceedings the day before he
died. He also had a letter in his pocket that suggests he took his life
because his marriage was over. Given they did not know about this,
there was little more staff could have done for him as he was already
receiving counselling for help with his marriage problems. I am
satisfied that, had they known he had received distressing news, they
would have dealt with it appropriately and may well have opened
another ACCT. We cannot know exactly what triggered his decision to
take his life at the time.
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RECOMMENDATIONS
HMP Altcourse
1 The Director and Head of Healthcare should ensure that a member of
healthcare is invited to attend all ACCT case reviews.
This recommendation has been partially accepted. The prison has
responded as follows: “All staff will be reminded of the need to have
appropriate personnel present at all case reviews.”
2 The Head of Healthcare should ensure that all healthcare professionals
are aware of the ACCT process and recording systems. It might be
necessary to have refresher training specifically targeted at healthcare
professionals.
This recommendation has been accepted.
3 The Head of Healthcare should implement an auditable system to ensure
that caseloads from the mental health team are handed over when any
staff are absent.
This recommendation has been accepted.
4 The Head of Healthcare and Safer Custody Co-ordinator should work
together to ensure that healthcare professionals are fully aware of their
duty and role in the ACCT process. This might be incorporated into the
training recommended above.
This recommendation has been accepted.
5 The Head of Healthcare should ensure that the in-possession medication
risk assessment procedures are clear to all staff and are carried out
appropriately. The Director should ensure this also forms part of the cell
searching procedures
The recommendation has been accepted.
6 The Head of Healthcare and the Pharmacist should review the medicine
management policy in relation to over the counter medication to ensure
that potentially unsafe practices cease. This should include:
(cid:127) a system to ensure that healthcare professionals know which
prisoners are on ACCT or at risk.
(cid:127) a system for ensuring nurses and officers do not give out more than
safe amounts of over the counter medication
The recommendation has been accepted.
7 The Head of Healthcare must instruct all healthcare staff, including
counsellors, to log all contact with prisoners to ensure continuity of care.
This recommendation has been accepted.
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8 G4S healthcare services should have in place a Service Level Agreement
with all external agencies, including the counselling service, contracted to
carry out services through them to ensure effective team work. The
Director of Altcourse should be satisfied that all contracted agencies
share information effectively.
This recommendation has been accepted.
9 G4S healthcare services should review System One to ensure that it is fit
for purpose taking into account the comments above.
This recommendation has been accepted.
National Offender Management Service
10 NOMS should approach the Law Society seeking their agreement to
issue guidance to all solicitors to notify prisons directly if they are
delivering difficult or distressing information to a prisoner.
This recommendation has been partially accepted. NOMS has
responded as follows:
“The Law Society have already been asked to agree to circulate a letter,
drafted by Safer Custody and Offender Policy, to legal advisors with
some information about what they should do if a prisoner they are
interviewing presents a risk of self harm or suicide. They declined to do
this although they did agree that they would draft their own practice note
to explain to solicitors their duty of confidentiality if a client discloses that
they may harm themselves. The Law Society feels that a pragmatic
approach is already taken by solicitors and that they would alert staff if
they thought an individual was at risk.”
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