Individual at Chelmsford

Investigation into the circumstances surrounding the
death of a man at HMP Chelmsford
in 27 November 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
The man was 36 years old when he died on 27 November 2007 having been found
hanging in his cell at HMP Chelmsford. The man was in the first week of a sentence
of 12 weeks imprisonment. My investigator and I offer our sincere condolences to
the man’s family and friends for their sad loss.
My report shows that the man had been treated for mental illness. He had fabricated
stories about the death of his mother and had told prison staff that two of his brothers
had killed themselves in prison. Although his mother is still alive, sadly he did have
one brother who had killed himself in prison over nine years previously. To lose one
member of the family in prison must be very difficult. To lose a second in similarly
tragic circumstances must be even more painful. I have at least been pleased to
learn from the man’s family, that on this occasion, they have felt better supported by
the prison than they had experienced in the past.
At the time of his death, the man was being monitored under the Prison Service’s
suicide and self harm support and monitoring procedures. I believe these
procedures were being operated properly and that, short of a one-to-one watch, all
that could reasonably have been done to support and monitor the man was in fact
done. On the basis of what was known at the time, I do not judge that a one-to-one
watch would have been justified.
I wish to thank the Governor of Chelmsford for making the necessary facilities and
information available to my investigator, and for the assistance of the Liaison Officer.
In the course of the investigation, I asked for a clinical review to be carried out into
the care and treatment the man received in custody. I am grateful for her assistance
in providing this review.
Since taking over responsibility for investigating all deaths in prisons in April 2004,
there have been eight apparently self-inflicted deaths at Chelmsford including that of
the man. Five of these deaths occurred in the period between November 2007 and
March 2008. My report into one of those deaths contained an identical urgent finding
to one in this report into the death of the man.
I must apologise for the delay in issuing this document. This was partly due to the
clinical review being delayed and partly to pressures of work within my own office.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2009
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CONTENTS
Summary 4
The Investigation Process 5
HMP Chelmsford 8
Findings 11
Issues 21
Conclusion 25
Recommendations 26
3
SUMMARY
The man was discovered hanging in his cell at HMP Chelmsford on the morning of
27 November 2007. He had been sentenced to 12 weeks imprisonment and had
been in prison for just six days when he died.
When he arrived at HMP Chelmsford, he was quickly identified as being at risk of
self harm or suicide. A nurse assessing him decided to arrange for the man to be
monitored under the Prison Service’s suicide and self harm support and monitoring
procedures known as ACCT (Assessment, Care in Custody and Teamwork). The
man told prison staff that he was withdrawing from drugs and that he had lost two
brothers who he said had killed themselves in prison. The nurse arranged for him to
be interviewed by a specialist detoxification nurse the following day. In the
meantime, arrangements were made for him to share a cell as it was felt
inappropriate for him to be alone.
During the night, the man asked to speak to a Listener (a prisoner trained by the
Samaritans). When this could not be done straight away, he became aggressive,
banging and kicking his cell door. However, arrangements were made for him to be
supplied with a Samaritans telephone which he accepted. Over the next few days,
the man made a number of requests to speak to Listeners, but they withdrew their
service because they said he only wanted tobacco from them.
At about 12.30am on 27 November, the night patrol officer checked the man.
Although the man was still alive at that stage, the officer noticed that he was
unusually quiet. The officer returned to the cell 40 minutes later, which was earlier
than his scheduled time, and discovered the man hanging. He immediately
summoned assistance from other staff and attempted to wake the man’s cell mate.
Unfortunately the prisoner concerned had taken prescribed medication which made
him sleep, and he did not hear the officer knocking on the cell door. However, the
officer did manage to wake him up, and he was able to support the man’s body for a
short time.
Once assistance arrived, the man’s cell was unlocked and prison staff entered and
cut him down. They immediately began resuscitation procedures and continued until
a nurse arrived. The nurse also assisted and resuscitation continued until
paramedics arrived. After carrying out their own tests, the paramedics decided that
the man had died.
I conclude that prison staff responded well to the problems that the man evidenced in
prison. I also believe that, on the facts as they were known at the time, it would not
have been justified to have placed him on a constant watch.
My report includes six recommendations including one that I regard as urgent and
which repeats a recommendation made in another report into a hanging at HMP
Chelmsford.
4
THE INVESTIGATION PROCESS
1. Once my office had been notified of the man’s death, the investigation was
allocated to one of my investigators. He contacted the Deputy Governor of
HMP Chelmsford, and arranged to travel to the prison on 29 November 2007
to open the investigation.
2. On 29 November, my investigator met the Governor. Also at the meeting was
the clinical reviewer, Clinical Governance Lead for Mid Essex Primary Care
Trust, the prison liaison officer, and the Deputy Governor. The Governor gave
my investigator an overview of what had occurred on the morning the man
was discovered. He said that following the man’s death he had personally
contacted the person identified in the man’s prison record as his next of kin.
However, when he spoke to the lady concerned, she told him that she did not
wish to be involved. He then looked in the record for any information about
the man’s parents and discovered that the man had told prison staff that his
mother had died. This was later found not to be true. In the meantime, the
man’s father had heard of his son’s death and contacted the Governor for
more information.
3. The Governor told my investigator that he had also arranged for all prisoners
being monitored under the Assessment, Care in Custody and Treatment
(ACCT) procedure to be reviewed. (ACCT is the Prison Service’s monitoring
and support system for prisoners at risk of suicide or self harm.) This was in
line with Prison Service guidance (vulnerable or at risk prisoners can
sometimes become anxious following the death of someone else and may
require additional support from staff or Listeners).
4. On 2 January 2008, the Coroner for Essex and Thurrock issued my
investigator with a copy of the post mortem report. The report, written and
prepared by a Home Office Registered Pathologist, notes the cause of death
as (1a) suspension.
5. The following month, one of my family liaison officers telephoned the man’s
sister, who was acting as the man’s next of kin. My family liaison officer
explained my role and offered the man’s family the opportunity to meet her
and the investigator. The purpose of offering the meeting was to enable the
family to contribute towards my report and ask any questions they would like
examined. The man’s sister decided that she did not require a visit, but did
have one question and asked to see the investigation report. She said the
family had been told by prison staff that an officer had noticed that the man
looked distressed at 12.50am and he decided to check him again earlier than
usual. The man’s sister wondered why, if her brother looked distressed, the
officer left him alone. I am pleased to say that my report has been able to add
further detail to the original information.
6. The man’s sister told my family liaison officer that the prison had offered
assistance with the man’s funeral expenses. She added that her older brother
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had also killed himself in prison, nine years previously, and described the
support from the prison at that time as being very little. On this occasion
much had improved. She said this had helped the family considerably.
Witnesses who have contributed to my investigation
7. A Senior Officer is a trained ACCT assessor and has been in the Prison
Service for four years. At the time of the man’s death, she had just been
promoted to Senior Officer (SO).
8. A prison officer has been in the Prison Service since July 2004. When he was
interviewed in connection with this investigation he was an officer, although he
has since been promoted to SO. For the purpose of this report I refer to his
rank as Officer.
9. A second Senior Officer is a trained ACCT assessor and, together with
another assessor at the prison, was responsible for rolling out the ACCT
implementation and training at the prison.
10. A second prison officer is one of the E wing officers. He has been employed
by the Prison Service for about 15 months.
11. A third prison officer has been employed by the Prison Service for over five
years.
12. Another officer has been in the Prison Service for three years. On 27
November 2007, his duty was to assist the night manager.
13. A fourth officer is an ACCT assessor. He has been employed by the Prison
Service for four years and, at the time of the man’s death, was an officer on E
wing.
14. A Registered General Nurse (RGN) has been employed by the Prison Service
for 16 years at Chelmsford.
15. A second qualified Registered General Nurse (RGN). She has been
employed by the Prison Service for over 11 years and works permanently on
nights.
16. Another nurse employed at the prison as the Substance Misuse Team leader
and interviewed the man on 22 November.
17. A prisoner arrived at the prison on the same day as the man and was
allocated to the same cell.
6
HMP CHELMSFORD
18. HMP Chelmsford is situated close to the town centre and serves the courts of
Essex and the surrounding areas. Much of the fabric of the prison is
Victorian, but there has been both some refurbishment of the original
buildings and modern residential units have been added to the main building.
Accommodation is provided for both sentenced and unsentenced male
prisoners, with about a third of the population being young offenders aged
between 18 and 21 years.
Assessment, Care in Custody and Teamwork (ACCT)
19. ACCT requires staff to identify any concerns, take action, and document those
actions for prisoners identified as at risk of suicide or self-harm. The ACCT
document should be available to all staff where the prisoner is located. Within
24 hours of the document being opened, the at-risk prisoner will be seen by
an assessor and have a case review meeting. The meeting draws up a care
and management plan, known as a CAREMAP, and a member of staff is
nominated as the case manager. Wing managers take on the role of case
manager, oversee the management of the ACCT document and attend case
reviews.
Code one and code two
20. In the event of urgent medical assistance being required, the prison has a
radio code system to alert medical staff to the emergency situation. Code one
informs staff that the patient has breathing difficulties; code two informs them
that the patient is bleeding. The system ensures that medical staff take the
correct emergency equipment with them and is intended to provide the
necessary medical care as quickly as possible.
Counselling, Assessment, Referral and Throughcare service (CARATS)
21. The Counselling, Assessment, Referral and Throughcare service (CARATS)
supports prisoners who have a history of drug or alcohol abuse. The service
can be accessed by healthcare or by the prisoner referring themselves.
First Reception Health Screen
22. The first reception health screen document is the national screening tool used
by the Prison Service. It is designed to highlight any medical or mental health
issues with new prisoners when they arrive at the prison.
Listeners
23. Listeners play an important part in supporting prisoners identified of being at
risk of suicide and/or self-harm. They are trained, selected and supported by
Samaritans to offer confidential emotional support, 24 hours a day, to fellow
7
prisoners in distress. This is overseen by the prison’s own Safer Prisons
Officer and by the Samaritans.
24. The Listeners scheme is confidential and any prisoner can ask to speak to a
Listener at any time of the day or night. Prisoners can access a Listener
easily by asking a member of staff who will then make arrangements for a
Listener to speak to them. During the hours that prisoners are locked in their
cells, anyone wishing to speak to a Listener can make the request from the
night staff on duty. I explain the scheme in more detail later in my report.
Police investigations of deaths in custody
25. Every death in prison custody is reported to the police as soon as it is
discovered. In the first instance, the police treat the area where the person is
found as a potential crime scene and, as part of their investigation, note the
names of everyone involved and those who have been in contact with the
body. Additionally, they note the identity of all those entering and leaving the
cordoned area. When the police are satisfied that the death is not suspicious,
my investigators are able to begin their own investigation.
Prison officer grades
26. There are three levels of uniformed officer grades. Prison officers are the
front-line supervisory staff and, in the majority of cases, prisoners have first
and most contact with them.
27. Senior officers (SOs) are the first grade of managers and act as a reference
point for prison officers. SOs are responsible for the day-to-day management
of their area, supervising staff and dealing with issues raised by prisoners.
28. Principal officers (POs) are the highest rank of the uniformed staff. They
supervise other uniformed staff and have operational responsibility for the
prison.
Prison Service Orders (PSOs)
29. Prison Service Orders are long term, mandatory instructions which are
intended to be in place for an indefinite period. Any mandatory instructions to
Governors are written in italics. Each PSO is given a title and unique
reference number.
Her Majesty’s Chief Inspector of Prisons
30. On 9 July 2007, Her Majesty’s Chief Inspector of Prisons, Ms Anne Owers,
carried out a five day announced inspection of HMP Chelmsford. In the
opening paragraph of her report (published in November 2007), Ms Owers
said Chelmsford suffered from all of the problems of an overcrowded prison
system. The paragraph goes on to say that the inspection revealed some
serious underlying issues requiring urgent attention.
8
31. As part of the inspection process, prisoners are surveyed and asked to
comment on how safe the prison is. The results of the survey showed that
around 40 per cent of the prisoners felt unsafe at the time. The Chief
Inspector noted a number of contributory factors, including the reception
procedures which did not provide sufficient protection or support for
vulnerable prisoners. Additionally, there were some serious deficiencies in
suicide and self harm arrangements and access to Listeners. Finally, the
survey showed that the relationship between staff and prisoners on the young
adult wing was not “sufficiently positive”.
32. Healthcare provision was described as mixed with some good primary care
services. However, “worrying deficits” were noted in mental healthcare and
the regime for inpatients.
33. The Chief Inspector described her report as disappointing, noting that
previous inspections had shown considerable improvement in performance
and culture. However, the latest inspection had shown that the prison had
been unable to withstand the combination of population pressures, increased
numbers, staff shortages and turnover. Ms Owers concluded that “managers
need to grip the key issues of safety, decency and activity, in order to make
the best use of the resources they have”.
Independent Monitoring Board (IMB)
34. Each prison has an Independent Monitoring Board (IMB) whose role is to
monitor the prison and report any concerns that they have about the way
prisoners are treated. Board members are able to visit any area of the prison
at any time and have direct access to any prisoner who they wish to see, or
who requests to see them. The Board holds regular meetings in the prison,
with the Governor attending for part of the meeting. The Board produces an
annual report that is submitted to the Secretary of State for Justice.
35. The Chelmsford Board has not raised similar issues in their latest report to
those identified in this report.
9
FINDINGS
36. Following the man’s appearance at Chelmsford Magistrates Court on 21
November, he was remanded into custody as a convicted prisoner pending
sentence. In the same vehicle en route to HMP Chelmsford was another
prisoner. When they arrived at the prison, they were placed into a holding cell
in the reception area where they waited until staff were ready to begin the
reception process.
37. The RGN was on duty in the reception department. Her duty that evening
was to screen and assess all new receptions into the prison, looking
specifically at the prisoners’ physical and mental health. The RGN was also
responsible for identifying any medical needs that a prisoner might have and,
if necessary, arranging for continuation of medical treatment.
38. During the screening procedure (which the RGN told my investigator took
about 20 minutes), the man said that he was withdrawing from drugs. At
interview, the nurse said the man was talkative and asked for medication to
deal with pain. She checked the man’s notes and read that he had been seen
by a police doctor when in police custody and had been prescribed
medication to help reduce the pain. Unsure what to do, the RGN telephoned
Essex Ambulance Service for advice. The person she spoke to said the man
could have the medication that he had asked for. The nurse described the
man as “over the moon” when told he could have the medication. The RGN
said she gave him the medication whilst he was in the reception department
and that his anxiety reduced as a result. As part of her assessment, and
having taken into consideration the man’s information that he was withdrawing
from drugs, the RGN arranged an appointment for him to be seen by a prison
detoxification nurse the next day.
39. In addition to his medical issues, the man told the RGN that his brother had
committed suicide in HMP Leicester three weeks previously. The nurse said
the man was anxious and, because she had some concerns for his safety,
she opened an ACCT document. The document, which was opened at
7.40pm, shows that the RGN made the following entry: “States he is feeling
suicidal due to drug withdrawal. Brother hung himself three weeks ago in
Leicester prison.” She then passed the document to a senior officer for
further action. At interview, the RGN said she had not been given any training
in how to complete an ACCT document and had done her own research into
how it should be done.
40. The senior officer completed the immediate action plan section of the ACCT
document at 7.45pm. Having assessed the information given to him, he gave
written instructions to staff for the man to be allocated to a shared cell and
observed at least hourly during the night and three times during the day.
Additionally, he gave instructions for the man to have access to a telephone
as required and, similarly, access to Listeners.
10
41. Before being taken to a cell, the man once again waited in the holding room.
Whilst there, the night patrol officer for E wing, the fourth officer, went into the
room and spoke to him. At interview, the fourth officer said he asked the man
how he was and he replied that he was fine. They had a brief conversation
during which the man told the officer that he was having a few problems, and
was waiting for another prisoner to be allocated to the same cell.
42. My investigator asked the fourth officer what he and the man had spoken
about. The officer said the man told him that his brother had killed himself in
prison two weeks earlier. The man also told him that he was not feeling well
due to the effects of withdrawing. The fourth officer said the man was making
good eye contact during the conversation and spoke in “an upbeat manner”.
He said the man was interested in what was going to happen over the
following days and gave him no cause for concern. He added that he asked
the man if he had any suicidal thoughts or intentions at that time, and the man
had said he did not. The man told the fourth officer that he was okay at that
point in time and, although he had had suicidal thoughts in the past, he did not
have any at that time. Because the man was being monitored on an ACCT
form, the fourth officer had explained to him what would happen during the
night, and told him that he would be checking him.
43. The man was allocated to cell E 1-28, along with another prisoner. As it was
late in the day, they had little time to familiarise themselves with the wing.
Within a short period of time, they were locked up for the night.
44. My investigator spoke to the other prisoner and asked him to describe the
man’s behaviour during the short time they were together. The prisoner said
that, when he arrived at the prison, he and the man had been allocated to the
same cell. The other prisoner described the man as erratic and volatile and
said he spoke daily about killing himself. He said the man was experiencing
problems withdrawing from drugs, adding that the man had told him he had
been using heroin, cocaine and anything else he could obtain. The prisoner
said the man first began talking openly about killing himself about a day after
they arrived at HMP Chelmsford. During the time they had been at court, the
man had not said anything similar.
45. At about 2.00am the following morning (22 November 2007), the other
prisoner pressed the cell emergency bell as the man had apparently collapsed
onto the cell floor. The clinical review notes that, when the night nurse
examined the man, she found him to be alert and orientated. The clinical
review adds that the man told the nurse he had collapsed twice previously,
although the review does not identify when he said this happened. The man
told the nurse that he was unable to sleep. The clinical review notes that
there was no evidence of withdrawal identified by the nurse at that time.
46. The fourth officer told my investigator that the man was due to return to court
for sentencing later that morning. However, when prison staff went to unlock
him, he refused to attend and said he was unwell. The officer contacted
healthcare and the nurse said that the man was fit to be taken to court.
Prison staff spoke to the man, but once again he refused to leave his cell and
11
attend court. As a result, the man was formally charged with an offence under
the Prison Rules.
47. The RGN had asked for the man to be assessed by a member of the
detoxification team and so the substance misuse team leader met him at
8.30am. At interview, the team leader said the man was fine and she had
seen nothing about his behaviour to cause her undue concern. She said he
told her that he was a little low in mood, which she told my investigator was
associated with withdrawal. The team leader said her assessment of the man
was that he required detoxification and a care plan. The clinical review notes
that, following the assessment, the man was placed on a detoxification
programme.
48. The substance misuse team leader told my investigator that a copy of the
care plan was given to the man, so that he could write anything that might
affect him during the detoxification period. The team leader also referred the
man to the prison CARATS team for additional support. She said at interview
that the man told her he wanted to give up drugs and that he appreciated the
help being offered to him.
49. At 2.50pm that day, the first officer carried out an ACCT assessment interview
with the man. The purpose of the interview was to prepare a feedback report
for a case review, which had been arranged to take place immediately
following the assessment. At interview, the officer told my investigator that he
went to the man’s cell to meet him. He described the man as looking
dishevelled, shaking, very tearful and unkempt. His cell was untidy, with dirty
clothing on the floor.
50. In order to interview the man, the first officer took him to a quiet room in
another part of the prison where they discussed the ACCT document and the
concerns raised by the RGN. The man told the officer he had a “chronic drug
habit” and was withdrawing from a wide range of class A drugs. The first
officer told my investigator that the man was happy to talk to him.
51. In his assessment report, the first officer wrote, “Very emotional and tearful.
Suffering from chronic bereavement of two brothers who committed suicide in
HMP Leicester and his mother who died of MRSA in Derby. He has three
children to estranged ex partner. Heavily detoxing from a wide range of class
A drugs, very heavy out of control habit.” The first officer also noted that the
man had told him that he had not made any recent attempt to harm himself,
but had done so about one year previously when he had taken an overdose of
amitriptyline. (Amitriptyline is prescribed as both a pain killer and
antidepressant.) The man added that, as a result of the overdose attempt, he
had been placed into hospital as an in patient under Section 2 of the Mental
Health Act 1983 for a 28 day observation period. The officer asked the man
how he felt about not having died. The man said he was pleased to still be
alive. The officer described the man as being animated, low in mood, weak
and “rattling” (an expression used in relation to drug withdrawal symptoms).
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52. When the first officer assessed the man’s ideas of suicide at that time, the
man told him he did have current thoughts which he described as fleeting. He
said his thoughts were always aimed at using a ligature, which he said would
speed up his death. On the positive side, the man said his reason for living
was his three children who he said he loved dearly. He added that he wanted
to make a new life with them when released from prison.
53. The final part of the assessment was to discuss and agree a care plan with
the man. It was agreed between them that bereavement counselling might be
required. It was also agreed that he should complete his detoxification
programme and then gain employment in the prison.
54. During the assessment, the man asked the officer to be allowed to remain on
E wing as he felt supported there. After speaking with the E wing manager,
the first officer was able to tell the man that he could remain on the wing as it
was felt better for him to be close to a detoxification nurse than might
otherwise be the case. At interview, the officer said the man was much
happier at this stage because the support systems were in place. He said the
man was tearful and, before leaving the room, he gave the officer a hug and
thanked him.
55. Once the ACCT assessment is completed, the next stage is to review the
assessment and care at a case review meeting. The purpose of the case
review is to consider the assessment and agree, as far as possible, how best
to keep the prisoner safe. It is chaired by a case manager, who in this case
was the first senior officer. Also at the meeting were the first officer and the
man himself.
56. At interview, the first senior officer said she had previously seen the man in
the wing. She described him as a “nice chap” who after a couple of days had
begun to “perk up”. She said he would often be seen wandering from cell to
cell trying to obtain “burn” (prison jargon for tobacco). The first senior officer
said the man would speak to staff and ask them normal everyday questions.
57. The first senior officer said that when the man joined the case review meeting
he was unsteady on his feet, but there was a noticeable improvement in how
he had previously looked. The case review, which was held at around
3.00pm that same afternoon (22 November), appears from the notes to have
been constructive. The summary, written by the senior officer, noted that the
man should complete the detoxification programme before a further
assessment could be made. She also wrote that the man should complete an
educational assessment before applying for employment. The first senior
officer recommended that the man should be referred for day care. She also
agreed and confirmed the level of hourly observations which had already
been put in place. Finally, she noted that the man had agreed to contact staff
for support if his mood dropped. Before closing the review meeting, the first
senior officer scheduled a further case review meeting for 28 November.
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58. When the review meeting ended, the first officer telephoned HMP Leicester
and asked for information about the death of the man’s brother three weeks
earlier. The person to whom he spoke told him that the information was not
true. (My investigator has since learnt from the man’s sister that, very sadly,
her older brother had indeed killed himself in HMP Leicester nine years
earlier.)
59. At interview, the fourth officer said that at about 9.30pm that evening the man
asked to speak to a Listener. The fourth officer was on night duty and was
not carrying keys, so he contacted the night manager, a second senior officer,
and asked him to unlock a Listener. In the meantime, whilst waiting for the
night manager to make his way to the wing, the fourth officer spoke to a
Listener through the cell door and told him that the man wanted to speak to
him. The fourth officer told my investigator that the Listener began to get
dressed in preparation for going to the man’s cell. The fourth officer then
returned to the man’s cell and told him that it would be a while before the
Listener would be with him, due to the night unlocking procedure. The man
apparently accepted this. However, after about ten minutes he rang his
emergency cell bell and asked the fourth officer how long it would be before a
Listener was with him. The fourth officer repeated that he would have to wait
until the night manager had unlocked the Listener’s cell. The fourth officer
said in interview that, over the next 30 minutes, the man became increasingly
agitated and began kicking and banging his cell door.
60. Due to the man’s behaviour, the fourth officer telephoned the night manager
and told him what the man was doing. The night manager said he could not
place a Listener with the man, as he had to consider the Listener’s safety.
The fourth officer returned to the man’s cell and told him that he was unable to
allow a Listener into the cell, but that he could use the Samaritans telephone
instead. The man agreed. The fourth officer arranged with the night manager
to unlock the cell door and pass the telephone to the man, which he did at
10.20pm.
61. As the man was being monitored under the ACCT arrangements, prison staff
were required to make a note in the ACCT document of any contact with him
and observations. The fourth officer recorded in the ACCT document that the
man had been banging his cell door. The officer made a further entry at
10.20pm noting that the night manager had been to see the man to issue the
Samaritans telephone. Two further entries were made between 10.30pm and
11.00pm. Both entries note that the man had reported that he was having
difficulty with the telephone. The night manager returned to the cell and
checked the telephone. It was found to be working correctly.
62. At 11.30pm, the other prisoner rang the emergency cell bell and told the
fourth officer that the man had cut his wrists. The officer immediately
contacted the night manager and he arranged for the night nurse to be taken
to the cell to deal with the injury. When the nurse saw the man, she was able
to treat and dress the injuries which she noted in his medical record as
superficial. As a precaution, and because he was being monitored, the night
manager increased the frequency of observations on the man that night from
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hourly to every 30 minutes. The clinical review notes that the man told the
nurse that he felt the detoxification programme was not working. The nurse
referred the man’s case back to the detoxification nurse for further review.
63. On 23 November at about 8.30am, the man was seen by the substance
misuse team leader and a member of the CARATS team. The reason for the
meeting was to discuss and assess the reasons for the self harm the previous
evening. The man told the nurse that he had not cut his wrist as a result of
the detoxification programme, but because he was in low mood due to the
suicide of his brother. The substance misuse team leader told my investigator
that after assessing the man again that she had no concerns relating to his
detoxification care plan and so made no changes to it.
64. My investigator asked the team leader if the man had been asked why he had
harmed himself. She said he told her that he had become frustrated at not
seeing a Listener. The nurse said that as he was not showing signs of
withdrawal, they had talked about alternative ways to deal with frustration
rather than self harm. The mood of the meeting was positive. The substance
misuse team leader and the CARATS team had no further dealings with the
man.
65. The investigator asked the man’s cell mate the other prisoner if he knew why
the man had cut his wrists. He described the injury as a cry for help and not a
serious attempt to end his life. He said the man had wanted to speak to a
Listener, but they had refused to speak to him. The other prisoner said the
reason Listeners would not see the man was because the man was always
asking them for tobacco.
66. Later that day, at about 7.30pm, the man asked again to speak to a Listener
but they refused to see him. In the ACCT document it was noted that,
whenever the man saw a Listener, he would ask them for tobacco which was
why they refused his request. As the Listeners did not make themselves
available to the man, the officer dealing with the request offered him the
Samaritans telephone which he accepted.
67. Over the next few days, the entries in the ACCT document show that the man
made numerous requests to see a Listener but, as before, they declined to
see him. Several entries in the ACCT document show that staff felt that the
man was being a nuisance by making numerous demands on their time and
ringing his emergency cell bell for frivolous reasons. For example, he would
ask officers for tobacco and then demand it when they refused to give him
any. But whilst a number of entries are negative, one officer noted that the
man was interacting well with other prisoners and had become more
independent. In contrast, another officer had noted that he was quiet.
68. On 26 November, the second officer’s duty began at 1.30pm and was
scheduled to finish at 10.00pm that evening. However, due to night staff
shortage, he was asked by a manager to remain on duty overnight and
agreed to do so. This meant that he would not be expected to leave the
15
prison until about 8.00am the following morning, over 18 hours from when he
started his duty.
69. After completing his normal scheduled duty, the second officer went to E wing
to take over as night officer. At interview, he said he carried out routine night
security checks and also checked all those prisoners on E wing being
monitored under ACCT. He said he spoke to all those being monitored and
introduced himself, telling them that he would be checking them during the
night. The second officer said that the man, who was being monitored hourly,
immediately asked for the Samaritans telephone. Another prisoner was using
it, so the second officer told the man that he would provide it once the other
prisoner was finished. Although he did not ask why the man wanted the
telephone, the second officer said he did ask him if he was okay and the man
replied that he was. The second officer made a note of the request in the
ACCT document, recording the time as 9.50pm.
70. At 10.45pm, the second officer went to the man’s cell to carry out a routine
hourly check. When he looked into the cell, the man asked him once more for
the Samaritans telephone, but it was still unavailable. At interview, the
second officer said the telephone was given to the man about 15 minutes
later.
71. The other prisoner told my investigator that the man used the Samaritans
telephone at about 11.00pm. During the conversation with the Samaritan, the
man had said that he was going to kill himself. The other prisoner said this is
what the man had told the Samaritans before during previous conversations
with them. He added that, due to being prescribed medication himself, he did
not hear the full conversation as he fell asleep. However, he believes that the
man was on the telephone for about an hour.
72. About 40 minutes later (11.40pm), the second officer carried out a further
check on the man. He told my investigator that when he looked into the cell
the man was not using the telephone. The man spoke to him and wanted to
apologise for the way he had spoken earlier. The second officer said that the
man had been agitated earlier when the telephone was unavailable and that
the man felt he needed to apologise to him.
27 November
73. At about 00.30am, the second officer carried out a routine ACCT check on the
man. He told my investigator that when he looked into the cell he saw the
man sitting on his bed looking at the cell wall. He described the man as
looking thoughtful. The second officer told my investigator that, although the
man had nodded to him, he had not spoken which was unlike his previous
response.
74. The second officer said that, because the man had acted differently to when
he had last seen him, he decided to carry out a further check. He did so at
1.10am (about 20 minutes earlier than the required hourly check). When the
second officer looked into the man’s cell he saw him hanging by a ligature that
16
had been attached to the top right hand side of the cell window. The second
officer said he could see that the man’s mouth was open and that his tongue
was protruding. His hands were clasped and his feet were on the ground,
with his knees bent.
75. At interview, the second officer said he banged on the cell door in an attempt
to wake the other prisoner, but was unable to do so. Using his prison radio,
the second officer told the radio operator that the man was hanging. He
immediately heard the night manager and the night nurse acknowledge the
message. The second officer said he banged on the cell door again and this
time woke the other prisoner. He asked the other prisoner to hold the man up
so that the pressure would be released from his neck. The other prisoner did
as asked. Whilst lifting the man, the other prisoner said to the second officer,
“He’s gone.”
76. The other prisoner confirmed to my investigator that he was woken up by the
second officer who asked him to look at the man. He said he jumped out of
bed and felt the man’s neck to check for a pulse, but could not find one. He
added that the man’s body was cold, describing it as “stone cold”. The other
prisoner said the man was hanging from the top of the cell window frame, with
his feet off the ground. He said the man had used the hem of a bed sheet as
a ligature. The other prisoner said he had seen the material before, when
another prisoner in a cell above his had used it to lower tobacco through the
cell window to the man the previous day. (The use of so-called ‘lines’ to
transfer items from cell to cell is an illicit but mainstream feature of prison
culture, especially in jails where the design of the windows facilitates it.) The
other prisoner said the man had rolled the material up and placed it in his
locker.
77. The third officer, who had been carrying out other duties, told my investigator
that he heard a code one message on his prison radio. The message told
staff that a prisoner was hanging on E wing. He immediately ran to E wing,
which he said is about 20 metres away from where he had been at the time.
He said that, when he arrived at the cell, he saw the second officer standing
outside. Using his own prison radio, the third officer asked the night manager
for permission to enter the cell. The night manager gave his permission and,
after breaking the seal on his emergency cell key pouch, the third officer
unlocked the door. As he opened the door he saw the man suspended by a
ligature. The third officer said he told the other prisoner to leave the cell,
which he did.
78. The second officer said he entered the cell and cut the ligature, using his anti-
ligature knife. The man fell to the floor. Due to a lack of space in the cell, the
two officers moved the man onto the landing. Once on the landing, the
officers began checking for signs of life but did not detect any. The second
officer said he began performing chest compressions whilst the third officer
lifted the man’s chin up to open his airway.
79. Whilst the two officers were trying to resuscitate the man, the second RGN,
who was the night nurse and who had heard the radio message, waited in
17
healthcare to be collected and taken to the cell. She told my investigator that
she does not carry keys at night. The only way for her to leave healthcare is
to wait for either the night manager or the assistant to let her out. At
interview, the second RGN said she heard the radio message and, after
collecting an emergency resuscitation equipment bag, she made her way to
the ground floor of healthcare to await the night manager. She said the bag
contained oxygen, an ambu bag (a facial mask used to push air into the
patient’s airways) and intravenous equipment. The second RGN added that,
although a defibrillator was available, she did not take it with her as it did not
work correctly because of a problem with the battery and she was unsure how
to operate it. (A defibrillator can restart the heart in some cases of cardiac
arrest by giving a electric shock. It detects the electrical activity in the heart
and gives automated instructions to the rescuer on what to do.)
80. The second RGN said the assistant night manager arrived at healthcare and
unlocked the gate. He then escorted her to E wing, which she estimated to be
about 90 metres away. When she entered the wing she saw the two officers
performing CPR and went to assess the man’s condition. She said she
checked his pulse and looked for any sign of breathing, but did not detect
anything. At the same time she asked for an ambulance to be called.
81. The assistant night manager told my investigator that he was in the
communications room when the code one message was made. He said he
immediately began to make his way to E wing, but was diverted by the night
manager who told him to unlock healthcare and collect the second RGN. The
assistant night manager said that healthcare is a long way from where he was
when the call was made; he estimated that it took between one and a half to
two minutes to reach the cell.
82. When he arrived, the second RGN was waiting by the healthcare gate. The
assistant night manager unlocked the gate and escorted her to E wing, which
is alongside healthcare. He estimated that it took a further two minutes to get
to the man (thus a total of between four and four and a half minutes from the
first call).
83. My investigator asked the assistant night manager how long it would have
taken the second RGN to get to E wing, had she been able to leave
healthcare using her own keys. He estimated it would have taken between
one and one and a half minutes.
84. The assistant night manager said that when he arrived at the man’s cell he
saw two officers performing cardio pulmonary resuscitation (CPR). Satisfied
that the officers and the nurse were dealing with the man, he decided to move
the other prisoner to another cell. He said he checked that the other prisoner
was okay and then returned to the man’s cell. He was then diverted by the
night manager to go to the gate to prepare for the ambulance to arrive. He
said an emergency response vehicle arrived first, followed by an ambulance.
The assistant night manager estimated the time to be 1.20am or 1.25am.
18
85. At about 1.25am, paramedics arrived at the cell and began carrying out their
own checks. The assistant night manager saw them take over CPR and then
make two or three attempts to place a tube down the man’s throat. He said
he was told later that they had difficulty due to the man’s larynx being broken.
The assistant night manager said he was then instructed by the night
manager to return to the communications room to ensure the local
contingency plans for dealing with a death in custody were in hand. At
1.45am, the paramedics stopped any further attempt to resuscitate the man
and confirmed that sadly he had died.
After the man’s death
86. The assistant night manager said that the Coroner’s office completed their
work and the man was taken from the prison to the mortuary. He said the
time was 4.05am.
87. Following the man’s death, prison managers ensured that all those prisoners
being monitored under ACCT were seen and reviewed. Additionally, they
issued a notice to prisoners telling them what had happened. Managers also
reminded prisoners about the availability of Listeners. The prison care team
were made available to any member of staff affected by the man’s death.
19
ISSUES
Assessment, Care in Custody and Teamwork
88. It is a Prison Service requirement that all staff working in prisons with direct
contact with prisoners receive basic training in how to open an ACCT
document and complete the relevant section. Overall, my investigator judged
the quality of the ACCT procedures was good. However, the RGN said at
interview that she had asked a manager earlier in the year for the training but
nothing had been arranged for her.
89. On 21 December 2007, my investigator wrote to the Governor telling him that
the RGN had not been trained in ACCT. The investigator suggested that the
Governor should satisfy himself that all his staff are trained in ACCT. At the
time of submitting this report, the Governor has not given any indication of the
remedial action he might take or has taken in relation to ACCT training. I
therefore make the following recommendation:
The Governor should ensure that all new and existing staff at
Chelmsford, including agency staff, receives basic training in ACCT.
Listeners
90. It appears that, after a number of callouts, Listeners refused to see the man.
The reason for their refusal was concerns about his behaviour and constant
requests for tobacco. The Listeners considered that the man was misusing
the system and withdrew their support. A night manager felt that the man’s
aggressive behaviour was such that it was unsafe to place a Listener in a cell
with him. One entry in the ACCT document notes that the man was
considered to be manipulative.
91. My investigator contacted a member of staff from the Prison Service’s Safer
Custody and Offender Policy (SCOP) Group to seek advice on the procedure
when a Listener refuses a request to speak to a prisoner or the service is
withdrawn. I understand that this does not happen frequently, but the
decision of Listeners not to see a prisoner should be managed with the
assistance of prison staff, such as the prison’s Safer Prisons Officer (or
equivalent postholder). The guidance my investigator received from SCOP
was that the prison should record that the prisoner does not have access to
Listeners and ensure they can use the dedicated Samaritans telephone.
92. Additionally, SCOP told my investigator that the Samaritans 'Guide to prisons'
contains a section on 'Misuse of the Listener service'. It states that in some
circumstances it may no longer be appropriate for Listeners to have contact
with a prisoner, who can be reassured that they may have access to the
Samaritans telephone as an alternative. The guidance says that, if Listener
support is withdrawn, this should be managed with the help of the Safer
Prisons Coordinator.
20
93. SCOP advised that Listener training, which is delivered by the Samaritans,
tells Listeners to explain to callers what they do and do not do (for example,
they do not provide tobacco).
94. SCOP confirmed that there is currently no specific guidance in PSO 2700,
which is the Prison Service’s policy on suicide prevention and self harm
management, as to what prisons should do when Listeners withdraw their
support to prisoners who have misused the service. I have been pleased to
learn that SCOP will consider updating the guidance on this issue.
95. In light of that undertaking, I make no formal recommendation on this matter.
However, I trust it will be taken forward in the action plan the Prison Service
will develop in response to this report. The Governor will also wish to satisfy
himself that Listeners at Chelmsford are not more likely to refuse to see fellow
prisoners than those in comparable jails.
96. I am satisfied that the night staff ensured that the man was offered the
alternative of the Samaritans telephone when it became clear that the
Listeners would not see him. It is not certain whether they were following
local guidance, or simply acting on their own initiative. Whichever it was, the
important thing is that the correct actions were taken.
Night nurses’ access to keys
97. Night nursing staff do not carry keys that would allow them to leave healthcare
and make their own way to a patient. Instead, they are required to wait for the
night manager or the assistant night manager to unlock healthcare and
provide an escort. In this case, it is estimated that it took over four minutes
before the nurse was with the man, although the nurse believes it to be
longer. In the worst case scenario, it could be that the night manager, or the
assistant, might be at the opposite end of the prison when required,
increasing the delay even further.
98. Whilst carrying out his enquiries at Chelmsford, my investigator immediately
raised the matter with the Governor as an urgent finding. On 20 December
2007, he followed this up in writing to the Governor as follows:
“Urgent. The nurse on duty in healthcare at night does not carry keys.
If urgent medical assistance is required, the nurse has to wait for either
Oscar one or two to unlock healthcare and then escort the nurse to the
scene. In The man’s case, Oscar two had to leave the
communications room and run to healthcare to collect the nurse, after
which, they then went to E wing. The officer estimated the journey took
about four minutes.
“I understand that you will deal with this immediately and issue both Oscar two
and the night nurse with keys secured in a sealed pouch.”
(Oscar one and Oscar two are the radio call signs for the night manager and
assistant night manager.)
21
99. On Christmas Day 2007, within a month of the man’s death, another
Chelmsford prisoner was found hanged in his cell. This was after the
investigator’s concerns about nurses’ access to keys had been reported to the
Governor both orally and in writing as a matter of urgency. However, as it
was Christmas and therefore a heavy demand on the postal system, I cannot
be certain as to which day he received the letter.
100. As my investigator was only a month into investigating the man’s death, I
asked him to investigate the second hanging as well. During this second
investigation my investigator found that, despite an assurance that immediate
action would be taken and the night nurse issued with keys, the procedure
had not been introduced.
101. The investigator gave immediate feedback to the Governor and also wrote to
him on 14 February 2008 regarding this matter. The letter said, “Once the
code one message on 25 December had been made, it took the Nurse eight
minutes to arrive at the patient. The delay was caused by her not having keys
and having to wait for healthcare to be unlocked.” In my subsequent
investigation report, I said I was not satisfied that the procedure at night was
safe and made the following recommendation: “The Governor in partnership
with the PCT should review as a matter of urgency the policy of not allowing
the night nurse to carry keys.”
102. Before issuing my report, the investigator contacted the Governor to ask him
what he had done in relation to the urgent finding. The Governor apologised
for not responding to the December letter. He told him that he had issued the
night nurse with a “Class 2” key and that this would speed up the response
time. (Class 2 keys allow free movement around the interior of the main
prison, but not access or egress from the main accommodation building.
Neither does the key allow the nurse to leave healthcare.) He went on to say
that due to healthcare being outside of the main accommodation building, it
was still the case that the nurse would have to wait for either the night
manager, or the assistant night manager, to unlock using the master key. The
Governor said that due to Prison Service national security restrictions, he is
not allowed to have more than one set of master keys in the prison grounds at
night. He said that unless he could obtain funding for an additional nurse to
be on duty at night and located in the main prison accommodation area, he
could do little to resolve the issue.
103. Although I have some sympathy with the dilemma that the Governor is faced
with, I still believe the current practice to be unsafe. I urge the Governor, PCT
and the Prison Service to examine the difficulties faced at Chelmsford (and
any other prison with similar issues), and find a resolution to the problem.
The Prison Service, the Governor and PCT should examine the
difficulties faced at Chelmsford and resolve the problem.
Clinical Care
22
104. The clinical reviewer is satisfied that the level of care given to the man was
appropriate and relevant to his needs. However she has commented on three
areas requiring action.
Record Keeping
105. The clinical reviewer comments on the quality of entries made in the man’s
medical notes by medical staff. She says that, although signed, the surname
of the person making an entry is not always legible and the record is of
substandard quality. As an example, the clinical reviewer highlights an entry
made on 22 November 2007. The person making the entry has simply written
“Substance Misuse assessment”. She points out that there is no entry
detailing how the man was assessed nor is there an assessment pro forma in
the record. The clinical reviewer suggests that the implementation of an
electronic system would improve the quality of record keeping.
The Governor, in partnership with the PCT, should consider how best to
improve the quality of medical record keeping.
Training
106. The clinical reviewer says in her clinical review that it is essential for all
healthcare staff responding to emergency medical situations to be
appropriately trained in the use of available emergency equipment.
Additionally, she says that all healthcare staff should be given appropriate
training in ACCT. (As I have already mentioned this point, I will make no
further recommendation here.)
107. The second RGN told my investigator that, although a defibrillator was
available, she did not take it with her as it did not work correctly. She also
said she was unsure how to use it.
108. In his letter to the Governor dated 20 December 2007, my investigator raised
the matter of the defibrillator. He wrote as follows:
“The defibrillator which was available on 27 November was not taken to the
scene. It would appear from the nurse interviewed that it was not working
correctly. However, when we tested it, it was working, albeit the battery was
low in charge. The manager did not know if a replacement battery was
available. Additionally and apparently contrary to PCT guidelines, it is not
tested on a daily basis. The Clinical Reviewer will comment on this in her
report.”
I have not been made aware whether the Governor has dealt fully with this
matter and therefore make the following recommendations:
The Governor, in partnership with the PCT, should ensure that
healthcare staff receive appropriate training in the use of the emergency
medical equipment provided.
23
The Governor, in partnership with the PCT, should ensure that
emergency medical equipment is routinely tested and a record kept.
Emergency response
109. The second RGN said in her evidence that, when attending a medical
emergency during the night, the nurse has to carry heavy medical equipment.
She said taking the equipment adds to the delay in reaching the patient.
110. In her clinical review, the clinical reviewer has identified that although medical
treatment rooms are available in the wings they do not contain emergency
medical equipment. She recommends that in order to aid response times, the
rooms should contain emergency equipment:
The Governor, in partnership with the PCT, should consider equipping
the wing medical rooms with emergency medical equipment.
24
CONCLUSION
111. The man made it very clear to everyone that he was struggling in prison, and I
judge that prison staff took his problems seriously. He was monitored under
ACCT and, when appropriate, the level of observations was increased
straightaway. His medical needs had been identified quickly and proper
procedures put in place to support him. In fact, the man welcomed the
support given and spoke about strengthening relationships with his children
once released from prison.
112. The man’s family have raised concerns that, although the second officer had
sufficient cause to return to the man’s cell to carry out a further check on him,
he left him alone between 00.30am and 1.10am. I have considered this
matter carefully. It seems to me that, although it was unusual that the man
did not talk to the second officer, he gave no indication of his actual intentions
when the officer looked into the cell. The man had demonstrated a number of
mood swings over the few days he was in prison (including: being angry,
talkative, hugging one member of staff and, shortly before he died, being deep
in thought). An additional safeguard was that the man was in a shared cell.
On balance, I do not believe that the second officer had any reason to suspect
that a constant watch should be put in place and that he should have
remained with the man.
113. As many of my reports have shown, it takes just a few minutes from placing a
ligature around the neck for death to occur. With hindsight it would be easy to
say that all those on ACCT should be monitored constantly. I do not believe
that to be either practical or dignified. Nor in the case of the man would it
have been warranted on the facts as they were known at the time.
25
RECOMMENDATIONS
1. The Governor should ensure that all new and existing staff at Chelmsford,
including agency staff, receive basic training in ACCT.
The Prison Service have accepted the recommendation
2. The Prison Service, the Governor and PCT should examine the difficulties
faced at Chelmsford and resolve the problem.
3. The Governor, in partnership with the PCT, should review as a matter of
urgency the policy of not allowing the night nurse to carry keys. (Repeat
recommendation)
The Prison Service have accepted the recommendation
4. The Governor, in partnership with the PCT, should consider how best to
improve the quality of medical record keeping.
The Prison Service have accepted the recommendation
5. The Governor, in partnership with the PCT, should ensure that healthcare
staff receives appropriate training in the use of the emergency medical
equipment provided.
The Prison Service have accepted the recommendation
6. The Governor, in partnership with the PCT, should ensure that emergency
medical equipment is routinely tested and a record kept.
The Prison Service have accepted the recommendation
7. The Governor, in partnership with the PCT, should consider equipping the
wing medical rooms with emergency medical equipment.
The Prison Service have accepted the recommendation
26