Individual at Birmingham

Investigation into the circumstances surrounding the
death of a man
at HMP Birmingham in November 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2009
This is the report of an investigation into the death of a man. He was found hanging
in his cell at HMP Birmingham in November 2008. At the time of his death he was a
remand prisoner, having broken the conditions of his bail on 6 October. He was 29
years of age. It was his first time in prison.
I extend my condolences and those of my colleagues to the man’s family. I hope this
report goes some way to answering any questions they may have. I regret that my
report is delayed and apologise for any additional distress that this may have
caused.
Since the Ombudsman started investigating deaths in custody in April 2004, there
have been 19 deaths in custody at HMP Birmingham, seven of which have been
apparent suicides, including that of the man. I note that several issues which are
dealt with in this report have been raised previously in other investigations.
The investigation into the man’s death was undertaken by an investigator. In
addition, a clinical review was conducted by a clinical reviewer on behalf of the local
Primary Care Trust (PCT). I am most grateful to him and his review is annexed to
this report. I have also had sight of an internal clinical review carried out by the
Acting GP Clinical Lead at HMP Birmingham prison. I would also take this
opportunity to thank all of the staff at Birmingham for their cooperation with the
investigation.
It is evident from the investigation that the man was a quiet young man who, for the
most part, kept himself to himself. None of us can say what was on his mind during
the last few weeks of his life, or be sure of the reasons why he took the actions that
he did. However, he had a history of mental health and drug problems and, although
he was referred for assessments by both the mental health and drug detoxification
teams, he was not seen during his five weeks in custody. Medication was
prescribed, but not all of it was given to him, and it may be that withdrawal from
drugs and his mental health difficulties became too much for him to bear.
Although the mental health and drug detoxification assessments were not fully
completed, I do not believe that discipline staff at Birmingham could have foreseen
the man’s actions, given the limited information available to them. However, in
addition to a number of healthcare recommendations I also make a number of
recommendations relating to record keeping, the operation of the personal officer
scheme and calling an ambulance in an emergency.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman October 2009
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CONTENTS
Summary
The Investigation Process
HMP Birmingham
Key Findings
Clinical Issues
Other Issues
Conclusion
Recommendations
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SUMMARY
The man was arrested whilst on bail and sent to HMP Birmingham in October 2008.
During the reception process he was assessed by a nurse. He told the nurse that,
although he was not currently taking any medication, he had previously been
admitted to a psychiatric hospital and had harmed himself on several occasions.
Although he expressed no concerns about his health, he told the nurse that he had
been using heroin every day.
After consideration of the man’s status the RGN (Registered General Nurse) referred
him to the drug detoxification team that evening and made a non urgent referral to
the primary mental health team.
He spent the night in the first night centre but, because of his late arrival, was not
seen by the drug detoxification nurse. Although unable to assess him the nurse
prescribed a number of drugs, in addition to the sleeping tablet prescribed by the
prison doctor, to alleviate any possible symptoms of drug withdrawal. The man
never received the drugs prescribed by the nurse, but the following evening did
receive the sleeping tablets prescribed by the prison doctor.
Despite his name being added to the following day’s detoxification clinic list, he was
never seen by a member of the team and neither did he receive the rest of his
prescribed medication. Having spent a week on the induction unit, he was moved to
one of the main residential units then several further cell moves took place before his
death.
Due to a backlog in primary mental health care assessments, the man’s referral was
not progressed until 21 October. Although one of the mental health team’s nurses
was asked to look into his background and contact the hospital where he had been
receiving treatment, he was not fully assessed.
In November, just before lunch, a member of staff found the man hanging and the
alarm was raised. Healthcare staff attended and resuscitation was attempted.
However, this was not successful and he was pronounced dead by one of the prison
doctors at 12.12pm.
My report makes a number of recommendations, the most significant of which relate
to the man not being fully assessed by either the drug detoxification team or mental
health team. I also draw attention to poor record keeping, highlight the apparent
failure of the personal officer scheme and regret the apparent delay in calling an
ambulance.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by an Assistant Ombudsman.
He met the Governor of HMP Birmingham and a duty Governor, explaining the
nature and scope of the investigation. Notices were issued to staff and prisoners
at Birmingham informing them of the investigation and inviting them to contact
the investigator who was appointed to conduct the investigation. The
investigator also met the Governor of HMP Birmingham and gave feedback
during the investigation.
2. The investigator spoke and liaised with the Independent Monitoring Board (IMB)
and members of the Prison Officers Association (POA). (IMB members are
independent and unpaid. They monitor day-to-day life in the prison to ensure
that proper standards of care and decency are maintained.)
3. The investigator was shown the cell and wing where the man spent the last
weeks of his life. The investigator reviewed his prison and health records and
other documentation, including telephone records, made available to him upon
request, and interviewed a number of staff at the prison. Although a notice was
published for prisoners to invite them to contact my investigator with any
information they felt was relevant to the investigation, none came forward. At the
time of the investigation one of the prisoners who occupied a cell next to the man
had been released and the other had been moved to another establishment.
The investigator made enquiries with prison staff as to the identity of any
prisoners on the wing with whom the man may have mixed. Officers on the wing
reported that he kept himself to himself and did not mix with other prisoners and
were unable to identify any prisoners who may have had contact with him.
4. An independent clinical review was undertaken on behalf of the local PCT by the
clinical reviewer. The investigator also obtained an internal clinical review, into
the man’s death by the Acting GP Clinical Lead at Birmingham prison.
5. The investigator spoke with a Detective Inspector (DI) of West Midlands Police,
who is acting on behalf of the Coroner. The investigator has also been in contact
with the Coroner’s office and a copy of this report will be sent to the Coroner to
assist him with his enquiries.
6. A family liaison officer contacted the man’s parents and, together with the
investigator, visited them at their home shortly after his death. The visit gave his
parents the opportunity to discuss my investigation and to raise any concerns or
questions they wished to be addressed as part of this process. His parents
raised a number of concerns:
(cid:127) Whether the prison was aware of the medication that he had been
prescribed whilst in the community and what medication he was
receiving whilst in prison.
(cid:127) If the prison was aware that he had attempted to take his life on two
previous occasions.
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(cid:127) Whether or not there was a referral system in place at the prison
whereby prisoners with known mental health problems are
automatically referred for a more thorough mental health evaluation, in
spite of their presentation at the time.
(cid:127) If the prison was aware that he was a drug user and whether he was
placed on any drug detoxification programme.
(cid:127) Whether the prison made any attempt to contact his GP or St George’s
Hospital.
(cid:127) His parents also explained that, despite their best efforts, it had not
been possible to visit their son during the five weeks that he spent at
Birmingham, explaining the ongoing difficulties they experienced in
trying to arrange a visit to see him.
(cid:127) Why he had been moved so many times during his time at Birmingham
and whether or not there was anyone that he could have talked to if he
was feeling vulnerable and low.
I have done my best to address these issues and I hope that this report helps his
parents better understand the events before and after his death. Having read
the draft report his parents agreed with the findings and my recommendations.
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HMP BIRMINGHAM
7. HMP Birmingham is a local prison serving the Crown Courts of Birmingham,
Stafford and Wolverhampton in addition to local Magistrates Courts. The prison
consists of 11 accommodation units which include the original Victorian wings
and additional accommodation, built in 2002, providing space for a further 450
prisoners. The prison can hold a maximum number of 1,450 prisoners.
Healthcare
8. Healthcare at Birmingham is provided by the local Primary Care Trust (PCT).
The PCT provides primary healthcare and contracts the Birmingham and Solihull
Mental Health Trust to provide mental health care services within the prison and
the in-patient facility.
Listeners and Insiders
9. Listeners are prisoners trained by the Samaritans to offer confidential support for
prisoners in distress. They are available 24 hours every day and will meet
prisoners to listen to their concerns. Insiders are also prisoners, who usually
work on first night and induction centres, who offer guidance and information to
new prisoners. Unlike Listeners, Insiders have no formal training.
PIN Numbers
10. The PIN number is a number given to prisoners which allows them to make
telephone calls to friends and relatives. For the first 24 hours after the PIN
number is first issued a prisoner can call any number they wish. After this period
of time has passed, prisoners are only able to phone numbers authorised by the
prison.
Visits
11. Prisoners are also advised that the last four digits of the PIN phone number
should be used by their relatives to use in order to book visits. In order to
arrange a visit the prisoner fills out the form, given to them during induction, to
record the details of those people they wish to receive visits from. If a visitor
rings the visitor line, or e-mails requesting a visit they are unable to do so unless
they provide details of the pin number. If friends or families contact the prison to
book a visit without the PIN number the prison notifies the prisoner that friends or
family had attempted to book a visit but had been unable to do so because they
did not know the prisoner’s PIN number. The prisoner is reminded that he must
forward this number in order that a visit can be booked.
Independent Monitoring Board Reports
12. In their annual report for 2007 the Independent Monitoring Board (IMB) raised the
issue of there being little primary mental health provision at Birmingham. In their
report for 2008 the IMB reports that, “There is still no primary mental health care
provision …” The Birmingham and Solihull District Coroner has raised this matter
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at inquests into two earlier prison deaths.
13. The IMB also reported a great deal of uncertainly within healthcare at the prison
as the current contract has been subject to a competitive bidding process. They
felt that this was having a destabilising effect on staff at all levels. The IMB
argued that most of the difficulties had come about because of faults in original
contracts coupled with uncertainty about what should have been agreed.
However, they report that strenuous efforts had been made by staff to put things
right.
HM Inspectorate of Prisons Report 2007
14. The last full inspection of Birmingham, by Her Majesty’s Chief Inspector of
Prisons, was in 2007. She said that at the time of her inspection there had been
a significant improvement and that a strong and committed management team
had succeeded in changing the culture within the prison. However, she
concluded that her report was overall disappointing, citing that Birmingham was
suffering from the pressures of an overcrowded prison system and that these
pressures had made it more difficult to deliver safe, decent and purposeful
outcomes for prisoners. She said that it was a credit to staff and managers that
Birmingham was a much better prison than when it was last inspected in 2000
and that the scale of achieving that task should not be underestimated.
15. Her report also highlights a number of concerns raised by my own report into the
man’s death. These included that the personal officer scheme was not fully
understood by staff and was not applied consistently. Officers did not maintain
an accurate diary of their contact with prisoners and did not always identify
significant events affecting them. Their entries were generally of a poor quality.
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KEY FINDINGS
16. In October 2008, the man was transferred from Stafford Police Station to
Cannock Magistrates Court, having been arrested the previous day for robbery
whilst on bail. At 5.00pm he was transferred from court to Birmingham prison,
arriving at 5.40pm. Escort staff recorded on his Person Escort Record Form
(PER Form – a document used by escort staff to record a prisoner’s known risks
and other information) that he had previously used drugs and had a “self
confessed alcohol problem”. It was indicated that a medical assessment, police
risk assessment form and court file were also attached to the PER form.
(Birmingham prison has been unable to provide copies of either the medical
assessment or police risk assessment form. It is not clear what happened to
these documents, or indeed if they ever arrived at the prison.)
17. In reception a Senior Officer (SO) recorded on the man’s wing history sheets,
“Remanded into custody. First time in prison, rules and regimes explained,
states fine no problems.” The SO said that he could not recall seeing a medical
assessment and police risk assessment form. However, he added that if a
medical assessment form had been transferred with him it would have been
immediately passed to the nurse in reception. The SO said that any police risk
assessment form would also have been noted by reception staff and
consideration made as to whether an Assessment Care in Custody and
Teamwork (ACCT) booklet should be opened. (The ACCT document is used to
assess, observe and support prisoners who are at risk. It highlights the problems
and possible trigger points of a prisoner at risk of self harm and delivers a
multidisciplinary plan to give support and help through a period of crisis.)
18. An Officer completed a Cell Sharing Risk Assessment. (The CSRA is a form
used to assess the risk that a prisoner would present to others when sharing a
cell.) The Officer recorded that it was the man’s first time in prison. He noted
that, although he had no concerns at the time, he had described himself as
someone who became angry and frustrated quickly and “tended to get himself
wound up”. The Officer concluded that he did not pose a risk to other prisoners,
but that the situation would need to be reviewed regularly.
19. At approximately 7.15pm a Registered General Nurse (RGN) working in
reception interviewed the man as part of the first night reception health screen.
(All prisoners are given a first night reception health screen when entering prison.
The aim of the screen is to identify any needs or health concerns that the
prisoner might have. This includes identifying a prisoner’s past history, including
mental health and drug concerns.)
20. The RGN recorded on the prison’s electronic medical information system (EMIS),
that the man had told her he was not receiving any prescribed medication at the
time. He said that he had previously been admitted to St George’s Psychiatric
Hospital, Stafford and been prescribed anti-psychotics and anti-depressants for
drug induced schizophrenia. He said that he had a history of deliberately
harming himself, having previously attempted to hang himself and take an
overdose, but currently had no such thoughts. He told the RGN that he had used
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drugs in the past month, taking heroin on a daily basis. He expressed no
concerns about his physical health.
21. The RGN told my investigator that all the medical information she gathered
during the health screen was obtained from the man alone. He gave her no
indication that he was at risk of self harm at the time. Had he told her that he
was in receipt of medication, she said she would have referred him to the prison
doctor. Following the assessment by the RGN, who used the mental health
triage criteria, he was referred on a non urgent basis to the primary care mental
health team and the drug detoxification team. His details were entered on the
relevant clinic lists.
22. At 7.59pm one of the doctors working on the induction unit that evening,
prescribed the man with Zopiclone, a sleeping tablet prescribed to assist the
relief of drug withdrawal symptons. (However, his prescription chart indicates
that his first dose of Zopiclone was not administered until the evening of the
following day.)
23. The man was transferred from reception to D wing, the prison’s first night centre,
where new prisoners spend their first night in prison. My investigator has been
unable to establish exactly when he arrived at the first night centre. An Officer,
who provided him with a smoker’s pack and PIN telephone number, gave my
investigator an approximate time based on his experience. He said that as the
GUIDED booklet, (a document used to record the induction process) was not
completed until the following day; it was most likely that the man would have
arrived late on the unit, sometime after 8.30pm.
24. A second RGN from the drug detoxification team, went to assess the man at
around 9.00pm, but was unable to do so as he had been locked into his cell. At
9.12pm she noted on EMIS, “Five were not seen due [to] time factor”. Although
she was unable to assess him she prescribed, in addition to the Zopiclone
prescribed by the prison doctor, a number of other drugs used to help alleviate
symptoms of drug withdrawal such as stomach cramps, nausea and headaches.
They included Prochlorperazine Maleate, Ibuprofen, and Hyoscine Butylbromide.
She told my investigator that because she was unable to see him, she could not
give the medication she and the prison doctor had prescribed to relieve his
symptoms, although the prescription was noted on EMIS as having been
administered. The investigator could find no evidence to suggest that he was
ever given the medication prescribed by her.
25. The second RGN provided a verbal hand over to the night detoxification nurse, a
Registered Mental Health Nurse (RMN), and member of the drug detoxification
team who was based on the detoxification wing in another area of the prison.
The second RGN noted in the handover diary that the man was not seen as
officers had locked him up.
26. At 10.43pm the RMN recorded on EMIS that the man was “Not seen because of
time and the officers had to lock him up before he was assessed.” She told my
investigator that she made this entry on EMIS following the second RGN’s
handover earlier that evening. The RMN explained that in early October 2008,
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she would not have had access to the induction wing to carry out drug
detoxification assessments or administer prescriptions once prisoners were
locked in their cells. (I understand that this has now changed and members of
the drug detoxification team are now able to access prisoners at any time of the
day and night.)
27. As the man had not been seen, his name was entered in the handover diary to
be assessed the following day, 8 October, by a member of the drug detoxification
team. However, he was again not seen due to a lack of time, the clinic doctor
having to see 20 patients within a two and a half hour clinic. As a consequence
he was added into the diary to be seen the following day, 9 October. However,
upon his transfer to N Wing he had no further contact with the drug detoxification
team.
28. The man’s induction continued on the morning of 8 October. The induction
officer interviewed him as part of the induction process and completed the unit’s
GUIDED booklet. The man told the officer that his family did not know where he
was. Although he revealed that he had never previously been in custody, he
claimed that he was not worried about it. The man said that he used alcohol
daily and had recently been using heroin and amphetamines. When asked if he
would benefit from a drug detoxification programme, he said that he would. He
told the officer that he had self harmed more than five years previously but did
not currently feel like harming himself. He confirmed that he had suffered from,
and had been treated for, depression and other mental health problems. The
officer noted that there were no concerns regarding his location in the prison and
that he was polite and cooperative during the interview.
29. During interview for this investigation the induction officer said that the man
would have been provided with a number of booklets and leaflets explaining the
prison’s procedures, including how to make applications for visits and telephone
calls and would have been greeted by one of the Insiders and told about the
Listeners and the Samaritans telephone. During his time on the induction unit he
was also seen by other members of prison staff including the Chaplaincy and
Legal Aid Services team.
30. At 8.44am, using his PIN phone number the man attempted to make a call to his
parents, but hung up. He called his parents again at 9.24am and spoke with his
father. He told his father that he was in prison and would write to tell them when
they could visit. He asked his parents to bring tobacco and money with them.
31. A third RGN saw the man at 10.10am and assessed him as part of the prison’s
Wellman health screen. She noted on EMIS that he had no relevant past or
significant medical history and recorded a number of responses to general
medical questions. She told my investigator that she based this on the
information provided to her by him.
32. Later that day the man was moved to N Wing, the induction wing, for him to
participate in the second stage of his induction.
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33. On 9 October, the man attempted to telephone his parents but because he had
not registered the number with the prison, the call was not connected.
34. The man wrote to his parents in a letter post marked 13 October. He asked them
to send him tobacco and shampoo and to pass on his whereabouts to a friend.
He also told his parents that he would understand if they did not want to visit him
in prison.
35. The man was relocated from N Wing to A Wing on 14 October. An officer wrote
in his Wing Sheets, “Arrived onto A wing A2-14, does not seem to be any
problems.” On 20 October, she wrote, “Has been a quiet week, he is a quiet
individual who tends to ‘get on’ with things, no problems to report.” She told my
investigator that she was the personal officer assigned the cell in which he was
placed. She could not recall introducing herself to him, saying that she did not
“… make a case of going round and saying I’m your personal officer …“ She
said that she could not recall him approaching her about the use of the PIN
phone or seeking information about arrangements for visits.
36. In a letter to his parents, post marked 20 October, the man wrote, “It’s started to
sink in now just how long it is gonna be that I’m going to be here.” He asked his
parents to arrange a visit when he was next in court. He would try and ring them
in the next couple of weeks, adding that he had to fill in a form in order that they
could be approved for visits, which he believed would “take a while”.
37. Due to a backlog in primary mental health referral assessments, a second RMN,
the only member of the Primary Mental Health Team (PMHT) at the time,
evaluated the referrals to identify prisoners who should be seen as a priority.
She identified the man as a priority and at a mental health team caseload
meeting on 21 October; he was accepted by the Mental Health In Reach Team
(MHIRT) for further assessment. An entry on EMIS records, “Discussed in
Community Psychiatric Nurse Caseload Meeting. Referral received. Diagnosis
of schizophrenia SW [a Clinical Psychiatric Nurse] to see.”
38. The man was added to the case load of a Clinical Psychiatric Nurse (CPN).
However, she said that on 24 October a colleague, a fellow CPN, accepted him
onto her case load, on 24 October, as she was more available. The CPN said
that she subsequently had no further involvement with him.
39. The second CPN was not accepting new cases as she was leaving the prison,
but said that she offered to assist by carrying out background work and check
ups on the referrals made to the first CPN at the meeting. The second CPN said
that the first CPN gratefully accepted the offer of help.
40. A member of the MHIRT said that the second CPN had not gone to the meeting
that morning in order that she could complete her caseload prior to leaving the
prison. Although not party to any conversation between the two CPNs, the
member of the MHIRT thought it correct to assume that the second CPN would
not have been taking over the man’s case.
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41. On 24 October, the second CPN noted on EMIS that the man was known to St
George’s Hospital and was under the care of a hospital doctor, who last saw him
on 12 September. She noted:
“Known to St George’s Hospital, Stafford. Under care of a hospital consultant,
last seen 12 September 2008. Summary of OPA [out patient appointment] at
that time indicates history of low mood. Previously prescribed Naltraxone
however not current prior to remand. Prescribed no other medication. St
George’s Hospital would prefer a Consultant to Consultant transfer of
information. Gave contact details for a prison consultant psychiatrist they will
contact. Secretary advises me that there are no acute or risk issues that we
need to be aware of until further information is conveyed.”
The second CPN said that the secretary did not pass a clinical opinion, but read
from the last out patient letter.
42. The second CPN said that she then informed the prison consultant psychiatrist
that the hospital consultant was to be in touch regarding the man’s history, in line
with South Stafford’s standard working arrangements. She also said that she
passed the information that she had been able to gather on him back to the first
CPN, adding that had any concerns been raised from her telephone contact with
St George’s she would have alerted her colleagues. The consultant psychiatrist
at the prison said that the second CPN did not make any handover either
verbally or in writing regarding the man.
43. It was the man’s birthday on 27 October, and he received a card from his
parents. In a letter to his parents post marked 28 October, he thanked them for
his birthday card, telling them that he had:
“… ordered a new pin no for my phone so I will ring u in next couple of weeks
ok. When I ring I’ll give you the code you need to visit, I wont be able to fill in
the application form for you to visit until I get a new phone no.”
He said that he had written the old number on his hand so he would remember it,
but that he had washed it off by accident. (However, he continued to use the PIN
phone system after this date, indicating that he still had access to the PIN
number.)
44. The man was moved to B wing on 29 October. On 31 October, he assaulted his
cell mate sustaining injuries to himself. He was treated on the wing by a fourth
RGN. She noted on EMIS that he had several lacerations that she had cleaned
and applied dressing to, noting that two cuts to his lip might require stitches. She
recorded that he was happy to wait for the evening GP for further assessment of
his injuries.
45. At an adjudication held on 3 November, the man pleaded guilty to a charge of
assault, explaining that he did not intend to hurt anyone but had just ‘lashed out’.
He was found guilty of the charge and given five days stoppage of earnings at 50
percent and seven days loss of association and gym as well as the use of his
private cash. On 5 November, he was located in a single cell on C wing, cell 2-
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27, following a cell sharing risk review, which was completed as a consequence
of the assault on another prisoner.
46. On 11 November, the man submitted a Prisoner’s Application for Change of
Visitor Details request listing the names of his parents. In a letter to his parents,
postmarked the same day, he told them the PIN number required for them to
book a visit and again requested that they bring tobacco with them.
Events in November
47. An Officer told police that at about 9.15am he unlocked the man’s cell door for
the association period. (Association is the time when prisoners are unlocked
from their cells and can associate with each other, make telephone calls, and
take showers etc.) He said he did not notice what the man was doing, only that
he did not reply.
48. At around 9.45am the man approached the SO and asked her where he could
obtain a pin phone credit form. The SO said that she showed him the box on the
wing in which the PIN application forms were kept but could not recall whether or
not he actually took the forms away with him. A second Officer told my
investigator that he recalled that the man did not leave his cell that morning for
association.
49. At 10.44am the man rang his cell bell. The second Officer told the police that he
had asked to use the telephone. The second Officer said that because he knew
he had not gone out for association, he let him leave his cell to make a call. The
man made a second attempt to phone his parents at 10.50 am; however the
number was disallowed again. Soon afterwards, the second Officer said that he
appeared at the office asking for a PIN application form. The second Office said
that he gave him a form, telling my investigator that he did not ask for assistance
in completing it.
50. An uncompleted PIN phone query form was found in the man’s cell after his
death. Although the form is undated it is of the type held on the wing and I
believe it was probably completed by him that morning. The application form
listed the telephone number of his parents, however the form was incomplete.
51. At approximately 11.40am a third Officer unlocked the cell for the lunch period.
On opening the door he saw the man hanging from the window bars of the cell.
He immediately raised the alarm by shouting for assistance to nearby
colleagues. The first Officer, who was supervising prisoners nearby, responded
immediately. A fourth Officer also went to the cell, having heard the Officers’
shouts for assistance. The officers went into the man’s cell. The first and third
Officers supported the man’s weight whilst the fourth Officer attempted to cut the
ligature from the window bar, but due to the thickness of the ligature he was
unable to do so.
52. The SO also responded to the shouts for assistance from the Officers. Upon
arriving at the cell, the SO radioed for assistance, asking that Hotel 2, the
emergency response nurse, go to C wing immediately. The SO then went into
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the cell.
53. A fifth Officer was returning to his office via C wing, when he saw the SO emerge
from cell C2-27 and run towards the office. The officer saw the man hanging and
went inside immediately to assist the officers already there. A sixth Officer, who
was in the vicinity, also went into the cell to provide assistance
54. A PO said that he too saw the SO leaving the cell while attempting to use her
radio as she hurried along. The PO used his radio at 11.42am to ask members
of the healthcare team to attend immediately.
55. The SO returned to the cell with an additional ligature knife. He saw that the
fourth Officer was having difficulty cutting the ligature from above, and so
attempted to cut it at the end around the man’s neck. The ligature was
eventually cut free from around his neck several minutes later by a seventh
Officer. (The Wing Observation Log records that it took approximately five
minutes for the ligature to be cut.) During interview for the investigation, the staff
said that the man did not respond throughout.
56. A nurse was Hotel 2, the emergency response nurse. She was with another
nurse in the nurses’ treatment room on B3 Landing, when she received the
emergency call to go immediately to C2 landing. (The nurses’ station is located
off the centre of the prison and was within a couple of minutes walk of the man’s
cell.) Although unaware of the nature of the emergency, Hotel 2 took the
emergency response bag and, with the other nurse, made her way to C2 landing.
57. Hotel 2 said that the man was lying motionless on the cell floor, with ligature
marks prominent around his neck. She told the investigator that she sent the
other nurse to fetch additional emergency equipment including the defibrillator
and oxygen and also to confirm that an ambulance had been called. Hotel 2 said
that she could gain no response from him and found no signs of life.
58. Hotel 2 immediately commenced cardio pulmonary resuscitation (CPR) with the
assistance of the fourth and sixth Officers. On her return to the nurses’ station to
collect further emergency equipment, the nurse informed another nurse of the
situation. Both nurses then went back to the man’s cell. They took the blue
emergency bag containing the Automated Electrical Defibrillator (AED), oxygen,
ambubag with face mask and other emergency equipment.
59. When the second nurse arrived at the cell, she found Hotel 2 and two of the
officers carrying out CPR. The second nurse attached the defibrillator to the man
but the machine indicated that no shock (to restart the heart) should be
administered and that CPR should be continued. The nurses and officers
therefore administered CPR until the paramedics arrived at 11.52am. The prison
doctor arrived at 12.00pm. The man had not responded to the resuscitation
attempts by nursing staff and paramedics, and the doctor pronounced him dead
at 12.12pm. (In his clinical review the clinical reviewer concluded that the efforts
to resuscitate the man were prompt and well executed. He cited the healthcare
response as an example of good practice.)
16
60. The control room incident log records that an emergency call was made to the
West Midlands Ambulance Service at 11.47pm. Although Hotel 2 asked for an
ambulance to be called, my investigator has been unable to establish who made
the request for an ambulance to attend.
61. The staff who discovered the man and responded to the emergency were invited
to a hot-debrief that afternoon. (A hot-debrief is a meeting held as soon as
possible after a major incident.) A review of prisoners at risk of harming
themselves was completed. I also understand that those officers involved in the
incident were approached by the care and welfare team. Several officers said
during interview that they were impressed by the level of care offered to
members of staff.
62. The man’s parents were told of his death by Family Liaison Officer, Governor
and Chaplain that morning. His parents commented on the sensitivity and
kindness shown to them by staff following his death.
17
ISSUES
Clinical issues
63. On his arrival at Birmingham on the evening of 7 October, the man was
assessed by a RGN, a member of the prison healthcare team. As a
consequence of his history of substance misuse, she referred him to a second
RGN from the drug detoxification team. However, due to his late arrival on the
induction unit, he was not seen that night by her. He was locked in his cell by the
officers in preparation for the prison entering the Night State, when all prisoners
are locked up and staffing levels are reduced.
64. An Operational Order on the Late Processing of Prisoners 137/2008, issued by
the Governor on 12 September 2008, advises staff the Duty Governor and Night
Orderly Officer will ensure that staff are available to supervise the processing of
prisoners who arrive late. The order goes on to say that:
“Prisoners identified as having immediate health needs will be given
necessary medical attention. Any prisoner identified as having immediate
mental health problems or detoxification problems will be seen by the
appropriate staff on the first night centre.”
The arrangements for the man did not meet the requirements of the Order, and
he did not receive the medical attention which he needed.
The Governor should remind staff on the Induction Unit to unlock prisoners
who have been identified as having immediate health needs in order that
appropriate treatment by healthcare staff can be provided.
65. The man was not seen by a member of the drug detoxification team either on 7
October, or over the following two days, due to a lack of nursing resources.
Upon his transfer to N Wing he appeared to be omitted from the drug
detoxification team’s list of assessments.
66. In his clinical review the clinical reviewer says that, although the man was known
to have a history of drug abuse and was prescribed treatment, a drug
assessment was not carried out. His only treatment appears to be medication
prescribed to relieve the symptoms of opiate withdrawal. The clinical reviewer
concludes that, when admission reviews have been missed because time is
short, there should be a “fail safe” system to ensure that they are carried out the
following day. I agree with his conclusions.
The Healthcare Manager and Drug Detoxification Team Manager should
ensure that when admission reviews have been missed as a result of lack
of time, there should be a “fail safe” system to ensure that they are carried
out the following day.
67. However, I would hope that it would seldom or never be necessary for the “fail
safe” system to be deployed on the day after a prisoner’s arrival, because the
Governor’s Operational Order should ensure that the necessary assessments
18
take place on the very first day or night of a prisoner’s custody.
68. Although the man was not seen by the second RGN from the drug detoxification
team, she noted on EMIS that a number of drugs, in addition to the sleeping pills
prescribed by the prison doctor, were prescribed to relieve any initial symptoms
of drug withdrawal. However she told my investigator that, because she was
unable to see him, she was unable to give him his medication. Although his
prescription charts show that he did receive his sleeping tablets on the
subsequent evenings, the investigator could find no evidence to suggest that he
ever received those drugs prescribed by the second RGN. Failure to administer
prescribed drugs is of great importance to any patient, but especially to a
prisoner, in custody for the first time, who may be experiencing drug withdrawal
symptoms.
The Healthcare Manager and Drug Detoxification Team Manager should
ensure that systems are in place to guarantee that medication prescribed
to prisoners is administered appropriately and on time.
69. In her internal clinical review the Acting Clinical GP Lead at HMP Birmingham
states that the man told nursing staff that he had a history of mental health
problems. He claimed that he had not seen a psychiatrist for some time, even
though he had actually done so only a month before his arrival at Birmingham.
She also reported that he informed staff of his previous history of self harm but
said that he had no current thoughts of harming and his behaviour did not raise
any concerns with staff. She said that on the basis of these observations, rather
than refer him for an urgent assessment that night by the CPN, he was actually
referred to the Primary Mental Health Team (PMHT).
70. Unfortunately, due to a backlog of work and shortage of staff, the man was not
assessed by the PMHT. His case was highlighted at a review of the prisoners
referred to the PMHT, but who had not been assessed. He was discussed at a
meeting on 21 October and referred for further assessment by a member of the
MHIRT. Background information was sought from St George’s Hospital and
arrangements were put in place for further contact between the hospital
consultant, the hospital contact and the consultant psychiatrist, but no contact
was made. The man had no further contact with mental health services at the
prison.
71. In her internal clinical review the Acting Clinical GP Lead said:
“The management of the man’s case was poor in that communication
failures occurred at several points.
(cid:127) He self-reported psychiatric history was not reliable, had nursing staff
known that he was currently under close review by the psychiatrist he
would have been referred to the CPN that night. The newly created PMHT
at that time consisted of one nurse who was physically unable to
undertake the workload. The dangers of this had been reported to senior
management on several occasions as had the very high vacancy rate and
19
sickness absence rate of nursing staff.
(cid:127) As he was locked up on the night of his admission and not seen by the
detoxification nurse, an opportunity to discover more pertinent information
was missed.
(cid:127) When his case was discussed at the MHT meeting he should have been
booked for an urgent review as he had already been in the prison for two
weeks.
(cid:127) The decision to wait for consultant-consultant discussion should have
been questioned and the prison psychiatrist asked to contact St George’s
Hospital as soon as possible to explain that such strategies are
inappropriate in a prison setting.
(cid:127) The prison cannot put the onus on outside agencies to contact us to
forward essential clinical information. Also if contact details are given,
they must be phone numbers which are manned or have answer machines
attached.”
72. In his clinical review the clinical reviewer confirms the Acting Clinical GP Lead’s
findings. He concluded that there appeared to be no identifiable consultation by
a prison doctor at any stage during the man’s stay in prison, despite his history of
major mental illness. He said that:
“There appears to have been communication failures, particularly in referral
procedures, which may reflect reduced staffing levels, consequent on poor
recruitment and retention.”
73. I am very concerned to read the Acting Clinical GP Lead’s and the clinical
reviewer’s findings, and in particular that the newly created PMHT was grossly
understaffed and that this had been reported to senior management on several
occasions. It cannot be stressed how important the speedy identification of
prisoners with mental health problems is in order that the correct care can be
provided. It is clear that in this instance the man was failed by the system.
Based on the findings and conclusions of the Acting Clinical GP Lead and the
clinical reviewer I make the following recommendations.
The local Primary Care Trust, Birmingham and Solihull Mental Health Trust
and Heads of Healthcare and the Mental Health In Reach Team should
urgently undertake a needs analysis and review of mental health provision,
including staffing levels, and satisfy themselves that the appropriate
mental health provision is being delivered at Birmingham prison.
The Healthcare Manager should satisfy herself that communication
between the primary health team and MHIRT is adequate, ensuring that
procedures are in place in order that staff are aware of and have
responsibility for the prisoners in their care.
74. In his clinical review the clinical reviewer said that, although the computerised
medical notes held on prisoners at Birmingham add clarity, there is no
20
identification of the role of the practitioner making the recording. He concluded
that, in order to facilitate case reviews, practitioners should add their role at the
time of entry. Additionally he notes that all the entries on EMIS were listed as
“consultations” when they might in fact be indicating another activity. In the light
of his findings, I make the following recommendation.
The Healthcare Manager should remind all healthcare staff of the need,
when entering entries on EMIS, to clearly identify their role and the nature
of their consultation/activity.
Wing history sheets
75. My investigator was unable to establish any detail about the time that the man
spent in custody from written prison records and, in particular, his wing history
sheets. After 20 October, and until his death, only two entries were made, one
relating to his assault of another prisoner and the other to the subsequent
adjudication. I am saddened that prisoners such as the man may have a lower
profile on the wings than other prisoners, and be less demanding of staff time
and attention. They may go unnoticed and, as a consequence, less is recorded
in their history sheets and less information is available for staff or for
investigations such as this. Birmingham’s own personal officer scheme expects
entries to be made at least once weekly and significant entries highlighted in the
wing observation book.
The Governor should remind all staff of the importance of completing wing
sheets and observation books, noting their interactions with prisoners.
Personal officers
76. Although a particular Officer was the man’s allocated personal officer when he
transferred to N Wing, she told my investigator that she did not formally introduce
herself. The officer said that she was the movements officer when he moved
from the induction wing to A wing, and was responsible for assigning him a cell
and completing a brief check as to how he felt. She also said that, because of
the particular cell where he was located, she was his personal officer. However
she told my investigator that she did not formally introduce herself during the
time he was on the wing. She said that she had not received any training with
regard to the personal officer scheme nor was she aware of any guidance for
staff.
The Governor should ensure that the Personal Officer Scheme is operated
properly and in accordance with the local protocol, reminding staff of their
roles as personal officers.
The man’s contact with his parents
77. During his time at Birmingham, the man and his parents wrote to one another on
a number of occasions. In his letters he told his parents that he was organising
his PIN phone contact and arranging for their names to be put on his visitors list.
However, it is apparent that he was unable to complete these tasks as he did not
21
use the PIN phone system successfully. It was only in the final letter to his
parents, postmarked 11 November, that he was able to provide them with the
last four digits of the PIN phone number which are required to book a visit.
78. The Ombudsman’s investigator made enquiries with regard to the information
provided to prisoners about making contact with their families, including PIN
phone arrangements and applications for visitors. He was satisfied that this
information was not only explained to prisoners during the induction process but
that they were also given information explaining the processes. Unfortunately
the investigator has been unable to establish whether or not the man simply had
difficulty in understanding how these processes were completed and was not
forthcoming in seeking assistance or if indeed he lacked sufficient motivation to
complete them.
Cell movements and access to Listeners
79. During his time at Birmingham the man moved cell five times. Having arrived in
reception, 7 October which was his first night, was spent on the first night centre.
He would have had access to both Listeners and Insiders, and be made aware of
their presence during the induction process. He was then briefly moved into
another cell on the centre the following day, 8 October, before being moved to N
Wing, the induction wing.
80. The man moved on 14 October from the induction wing to A Wing, before being
moved to B wing on 29 October. His last cell move to C Wing took place on 5
November, as a consequence of being found guilty of assaulting another
prisoner. Although I agree that he appears to have moved frequently, when
seen within the context of life in a local prison, I believe his movements around
the prison were not excessive. He would have had access to Listeners and the
Samaritans’ telephone whilst located on any of the wings.
Emergency codes
81. During interview Hotel 2 told the investigator that she was not aware of the
nature of the emergency that she was attending when she received the call to
attend C2 landing immediately. Although I appreciate that there are no
mandatory requirements to use any specific emergency code system, many
prisons use a call system such as red (for blood loss) and blue (for breathing
difficulties). The codes inform staff of the nature of an emergency in language
that is easily understood. Although I make no recommendation, I invite the
Governor to consider the introduction of a code system for emergency calls.
Delay in calling ambulance
82. The man was discovered by the third Officer at about 11.40am, but it was some
five minutes later at 11.47am before the control room made an emergency call
for an ambulance to attend. Although Hotel 2 asked for an ambulance to be
called as soon as she reached the cell, the investigator was unable to establish
who made the emergency call. I appreciate that these timings may not be
completely accurate but it would appear that it was at least five minutes before
22
the emergency call was made. Action was taken on the instruction of a nurse
and not by officers who were first to arrive at his cell.
83. A Governor’s Order, 36/2008 on Medical Emergencies issued on 26 March 2008,
states that,
“The Officer (or other person) supervising the incident scene may request
that an ambulance is called, prior to the arrival of Hotel 2, Oscar 2 or Oscar
3, if they believe that the prisoner’s condition is sufficiently serious to warrant
doing so. This is particularly important where the prisoner appears to be
unconscious and/or not breathing.”
I therefore make the following recommendation.
The Governor should remind staff of the contents of his Governor’s Order
36/2008, emphasising that any member of staff can authorise the calling of
an ambulance in an emergency.
Incident reports
84. My investigator has also drawn to my attention the fact that a number of officers
who responded to the alarm being raised did not complete post incident
reports/statements. Although I make no formal recommendation, I would ask the
Governor to remind staff of the importance of completing comprehensive and
accurate statements after such events.
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CONCLUSION
85. When the man entered prison he alerted staff to his history of mental illness and
drug abuse. As a consequence he was referred immediately for assessment by
the drug detoxification scheme. However, the gravity of his mental health
problems appears to have been lost in his explanations to staff. Although it was
recognised that he would require a mental health assessment, it was not
considered that an urgent referral was necessary and he was never assessed.
Of the five weeks that he spent at Birmingham, little is known about his time at
the prison.
86. It is possible that the outcome might have been different if there had been an
early intervention by mental health services at Birmingham and if mental health
support for the man had been provided. Instead we have a sad story of a young
man, in custody for the first time, who seems to have been overlooked by prison
and healthcare staff.
24
RECOMMENDATIONS
1. The Governor should remind staff on the Induction Unit of the need to unlock
prisoners who have been identified as having immediate health needs in order
that appropriate treatment by healthcare staff can be provided.
Accepted – Operational Order 105/2009 explains the duties for the effective
handover to night staff to ensure prisoners are seen on their first night.
2. The Healthcare Manager and Drug Detoxification Team Manager should ensure
that when admission reviews have been missed as a result of lack of time, there
should be a “fail safe” system to ensure that these are carried out the following
day.
Accepted
3. The Healthcare Manager and Drug Detoxification Team Manager should ensure
that systems are in place to guarantee that medication prescribed to prisoners is
administered appropriately and on time.
Accepted – Systems have been reviewed and are being audited to ensure
compliance
4. The local Primary Care Trust, Birmingham and Solihull Mental Health Trust and
Heads of Healthcare and the Mental Health In Reach Team should urgently
undertake a needs analysis and review of mental health provision, including
staffing levels, and satisfy themselves that the appropriate mental health
provision is being delivered at Birmingham prison.
Accepted
5. The Healthcare Manager should satisfy herself that communication between the
primary health team and MHIRT is adequate, ensuring that procedures are in
place in order that staff are aware of and have responsibility for the prisoners in
their care.
Accepted – Primary health care team created November 2008 and mental
health register jointly managed by the second RMN.
6. The Healthcare Manager should remind all healthcare staff of the need, when
entering entries on EMIS, to clearly identify their role and the nature of their
consultation/activity.
Accepted – All team leaders have responsibility to ensure this happens.
7. The Governor should remind all staff of the importance of completing wing
sheets and observation books, noting their interactions with prisoners.
Accepted – An operational order is written reminding staff of this requirement
25
(81/09)
8. The Governor should ensure that the Personal Officer Scheme is operating
properly and in accordance with the local protocol, reminding staff of their roles
as personal officers.
Accepted – Operational order 197/2008 outlines the personal officer scheme
9. The Governor should remind staff of the contents of his Governor’s Order
36/2008, emphasising that any member of staff can authorise the calling of an
ambulance in an emergency.
Accepted – Operational order 86/2009 outlines this requirement.
26