Individual at Chelmsford

Investigation into the circumstances surrounding the
death of a man at HMP& YOI Chelmsford in January 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2009
This is the report of an investigation into the death of a prisoner at HMP&YOI
Chelmsford, in January 2008. The man had a long history of mental health
difficulties and had threatened to take his life many times during his periods of
imprisonment. He seriously harmed himself on more than one occasion, including
during his time at Chelmsford. As a result the man was subject to monitoring to
ensure he did not harm himself and the procedures appear to have been carried out
properly on the whole. Nevertheless, within three months of arriving at Chelmsford,
he was found hanging in his cell. Despite resuscitation attempts the man was
pronounced dead upon arrival at hospital.
I must apologise for the delay in publishing this report. The investigation was initially
led by one investigator who has since left the Ombudsman’s office and the
investigation was completed by an Assistant Ombudsmen and a senior investigator.
One of my family liaison officers contacted the man’s next of kin and maintained
contact with them throughout the investigation. A clinical reviewer, on behalf of Mid-
Essex Primary Care Trust, undertook an independent clinical review into the clinical
care received by the man in Chelmsford. I am grateful to her for her assistance. I
am also grateful to the Governor and staff of HMP Chelmsford, who fully co-operated
with the investigation.
I have found that the man received the same level of care at Chelmsford as he had
at the other prisons. Healthcare and discipline staff worked hard to support the man,
who clearly was suffering with his mental health. Within hours of being relocated
from healthcare to a prison wing, he apparently took his own life. The man’s death
was the sixth such death at Chelmsford since the Ombudsman became responsible
for investigating all deaths in prison in April 2004. Since the man’s death there have
been another three apparently self inflicted deaths. There do not appear to be any
particular similarities between the other deaths at Chelmsford and that of the man.
However, I have also examined the procedures in place for discharging prisoners on
ACCT documents from healthcare and considered the training needs of staff on night
duty. I have raised concerns and make recommendations accordingly. I make
seven recommendations.
This version of the report, published on the Ombudsman’s website, has been
amended to remove the names of the man who died and those staff and prisoners
involved in the investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman August 2009
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CONTENTS
Summary 5
Investigation process 6
HMP Chelmsford 8
Suicide and self-harm monitoring 9
Samaritans 9
Listeners 9
CARAT 9
Chaplaincy 10
Radio Call Signs 10
Events leading up to the man’s death 11
Post Mortem 20
Contact with the family 20
Staff and prisoner welfare 20
Issues considered in the investigation 21
Recommendations 27
3
SUMMARY
The man was discovered hanging in his single cell at 10.00pm on 8 January 2008 in
Chelmsford. He had been sentenced to two years imprisonment in December 2005.
He was released on licence, but breached the conditions of his licence, and was
recalled to serve the remainder of his sentence in prison. During his sentence, the
man spent time at HMP High Down, Belmarsh, Edmunds Hill, Littlehey and Bedford.
He arrived at Chelmsford in October 2007.
The man had a history of mental illness. He complained of hearing voices,
particularly a male voice which told him to kill himself. During his prison sentence he
had been identified as someone who was at serious risk of harming himself and had
made a number of previous attempts to kill himself. Staff at High Down considered
that the man’s “risk of death [from self-harm] was extremely high”. During his
sentence, the man was frequently monitored under the ACCT (Assessment, Care in
Custody and Teamwork) process, which is a support system for prisoners at risk of
suicide and self-harm. He was often monitored constantly by staff. The man spent
much of his sentence located in the healthcare centres of the prisons where he was
held.
When the man arrived at Chelmsford he was still being monitored on an ACCT
document. His ACCT transfer plan from Bedford noted that he wanted to take full
part in the regime at Chelmsford and could be located on the wings rather than in
healthcare. However, the man spent the majority of his sentence at Chelmsford in
the healthcare centre, often monitored by constant observations.
I judge that healthcare staff worked hard to support the man’s needs whilst keeping
him safe. They treated him with respect and kindness and made sure that he was
involved in decisions being made about his care. The man asked twice to move
from healthcare to a normal wing location. Both times he was moved to a wing, but
then threatened to harm himself and was quickly returned to healthcare.
After consultation with a psychiatrist and a period of settled behaviour with no more
episodes of self-harm, the man was moved to B wing early in January and was
placed in a single cell. He remained on an ACCT with hourly observations.
At 9.25pm on the day of the move, the man rang his cell bell and was seen by an
officer who had started his first ever night shift. The man told the officer that he was
hearing voices that were telling him to kill himself. The officer reassured the man
and then asked if he would be okay while the officer continued with his duties. The
officer said he would be back to see him later. The man told the officer not to forget
about him.
At about 10.00pm, the officer responded to another prisoner who had harmed
himself. He radioed for medical and staff assistance before returning to the man’s
cell to check on him. There he saw the man hanging from the cell window. The
officer immediately went into the man’s cell and was quickly joined by other officers
and a nurse. The man was cut down and resuscitation was started. An ambulance
was called and the man was taken to hospital where he was pronounced dead on
arrival.
4
THE INVESTIGATION PROCESS
1. The investigation was allocated to an investigator who was assisted during
the investigation by a colleague. The investigator visited Chelmsford to open
the case three days after the death. The Governor and his staff provided the
man’s core record and a number of other documents. The investigator met
members of the chaplaincy, and arrangements were made for him to meet
members of the Prison Officers’ Association (POA) and Independent
Monitoring Board (IMB).
2. Notices were issued to staff and prisoners informing them of the investigation
and inviting anyone with relevant information to contact the investigator. No
one responded to these notices. The investigator was given unrestricted
access to the prison, staff, prisoners, and documentation relating to the man.
I am grateful to Essex police for sharing their investigation documents with the
investigator.
3. The man’s death was the sixth apparently self inflicted death to have occurred
at Chelmsford since April 2004, when the Ombudsman became responsible
for investigating all deaths in prison. Sadly, since the man’s death there have
been three further apparently self inflicted deaths.
4. Prison officers, members of healthcare staff, the Independent Monitoring
Board and prisoners were formally interviewed by the investigator, and those
interviews were tape recorded. The interviews have been transcribed and
interviewees invited to sign and return copies of the transcripts.
5. The two investigators originally allocated to the case left the Ombudsman’s
office before the completion of the investigation and so it was concluded by an
Assistant Ombudsman and a senior investigator.
6. Mid Essex Primary Care Trust (PCT) were asked to conduct a clinical review
of the man’s care and treatment whilst at Chelmsford. The PCT appointed a
clinical reviewer to undertake the review, which was received by the
Ombudsman’s office in August.
7. A family liaison officer from the Ombudsman’s office contacted and
subsequently met the man’s family with the investigator. They asked why the
man was moved to HMP Chelmsford. They were concerned that he was
located in a single cell so soon after being moved from healthcare. When the
man’s mother spoke to him on the Monday before his death, she said that he
seemed happy. He spoke to his partner on the Tuesday and again sounded
fine. The family asked whether it was the man’s decision to move to the wing
as they believe he would have preferred to stay in healthcare where his
cousin was located.
8. The family had been told that, at 9.25pm, the man saw an officer on the wing
and told him he was hearing voices. They believed the officer returned to the
cell at around 10.00pm when the man was found hanging. They wanted the
investigation to establish exactly what took place. The family wanted to know
5
whether the man had pressed his cell bell to alert the officer at 9.25pm, what
medication he was prescribed and where he was certified as having died.
They were concerned that they were not informed of his death until 4.00am.
After the man had died the family saw the ligature mark on his neck and
wanted the investigation to clarify exactly what was used to make the ligature,
what it was attached to and who cut him down.
9. The family liaison officer and one of the investigators also met the man’s
partner who wanted to know whether Chelmsford had properly assessed the
man’s vulnerability and risk to himself. She wanted to know whether the man
had been aware of, and offered support after, the death of another prisoner at
Chelmsford in December.
10. The man’s partner was concerned that, on the day of death, having told the
officer he was hearing voices, the man was left alone in his cell and was not
offered a Listener or other support. The man’s partner was concerned that he
had not been offered the same level of support at Chelmsford that he had
received at other prisons.
11. The investigator wrote to HM Coroner to inform her of the nature and scope of
my investigation and to request a copy of the post mortem report. Upon
completion, this report will be sent to the Coroner to assist her enquiries into
the man’s death.
6
HMP CHELMSFORD
12. HMP&YOI Chelmsford is a category B local prison which serves the courts of
Essex and surrounding areas. It holds predominantly sentenced and
unsentenced adult male prisoners but almost a third of the population is made
up of young offenders aged between 18 and 20 years. The prison
accommodation is split between the original Victorian wings and newly built
residential units. Like most local prisons, there are constant population
pressures and Chelmsford is one of the most overcrowded prisons in England
and Wales.
13. Healthcare is provided in a spacious and well equipped two storey building
completed in 2004. A large day-care centre has a welcoming main area with
comfortable seating, displays of prisoners’ poetry and art, and interview and
group rooms. There is an inpatient unit with 12 large individual cells, which
are fitted with safe furniture, except for two cells that have hospital type beds.
14. B wing is one of the older Victorian wings. It has three landings and holds 132
prisoners with 44 on each landing.
15. Her Majesty’s Chief Inspector of Prisons inspected Chelmsford in a full
announced inspection in July 2007. The inspection revealed a prison
suffering from all the problems of an over-crowded prison system. The
population was very fluid with prisoners staying a relatively short time and with
insufficient activity to occupy them. Staff turnover was high and shortages
were a constant feature.
16. The inspection found that healthcare staff worked hard to provide a decent
standard of care and were committed to improvements. The inspectors found
that the health centre was an excellent environment for patient care. There
had been a renewed focus on prison health from the local Primary Care Trust
since reorganisation, but progress had been slow. Clinical skills were not
used to best effect, and some aspects of service delivery were not well
organised.
17. A good day-care programme was available for prisoners with mild to
moderate health problems, but the Mental Health In-Reach Team did not work
with the psychiatrists. Prisoners with severe mental illness were cared for by
the primary care team and did not have integrated multi disciplinary treatment.
The levels of patient engagement on the inpatient unit were too low, their time
out of cell was too short, and they had very poor access to therapeutic or
rehabilitive day-care. The use of strip clothing (special clothing made from
material that cannot be ripped and therefore suitable for patients at risk of
self-harm) and CCTV to monitor patients at risk of self-harm was of particular
concern to the Inspectorate.
18. The inspection identified that the availability of Listeners (prisoners trained by
the Samaritans to offer confidential support to other prisoners) in Chelmsford
was generally poor. Initial self-harm monitoring assessor reports were found
to be lacking in detail and there were insufficient monitoring entries that
7
showed positive engagement by staff. There was, however, evidence of a
multidisciplinary approach to the management of prisoners on open suicide
and self-harm monitoring documents. Chelmsford was commended for its
support group for prisoners on self-harm monitoring.
19. Every prison in England and Wales is monitored by an Independent
Monitoring Board (IMB) formed of members of the local community. Board
members have right of access to every prisoner and every part of the prison
and also to the prisoners’ records. Each IMB produces an annual report, the
most recent report available for Chelmsford covers the period 1 September
2006 to 31 August 2007.
20. The IMB reported that “Prisoners have better access to Healthcare than they
would ‘outside’ and that mental health provision was readily available”. The
Board praised the “excellent management and dedication in the Healthcare
department” which provides an “enviable service”.
21. In respect of safer custody, the IMB reported that the Safer Custody Team
was enthusiastically led and staffed. The report noted the integrated and
multi-disciplinary approach to addressing suicide and self-harm issues. Like
the Inspectorate, the Board commented that the provision of prison-wide
Listener services was problematic.
Suicide and self-harm monitoring
22. As at all prisons, Assessment, Care in Custody and Teamwork (ACCT) has
been introduced at HMP Chelmsford to monitor and support prisoners
assessed as at risk of suicide or self-harm. (The previous system was known
as the F2052SH procedure.) Once placed on ACCT, the prisoner is observed
at pre-determined intervals according to the perceived level of risk. The
ACCT document is reviewed on a regular basis by key people who know the
prisoner at risk or are involved in their care.
Samaritans
23. The Samaritans is an independent organisation which has trained volunteers
that will listen to prisoners’ concerns. Prisoners at Chelmsford are able to talk
freely and in confidence with the Samaritans using the telephones provided
on the wings.
Listeners
24. 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.
Counselling, Assessment, Referral, Advice and Throughcare (CARAT)
25. In common with other prisons, prisoners in Chelmsford can access the
CARAT team over any concerns with regards to drugs or alcohol abuse.
8
Chaplaincy
26. Chelmsford has a dedicated chaplaincy team who cater for all religious and
spiritual needs. They are supported by a number of visiting religious leaders.
Prisoners can apply to attend chaplaincy services.
Radio call signs
27. At Chelmsford, staff use specific call signs when using their radios and
alerting staff to medical emergencies. The call sign ‘Oscar 1’ is given to the
Orderly Officer (the prison officer in charge of the prison, known as the Night
Orderly Officer during the night). ‘Oscar 2’ is the call sign given to his or her
deputy. A ‘code 2’ call sign denotes a situation requiring medical assistance
which is not felt to be life threatening. A ‘code 1’ call sign is used when
medical assistance is urgently required due to a life threatening situation.
9
EVENTS LEADING UP TO THE MAN’S DEATH
28. The man who died was serving a two year sentence for driving related
offences. He began his sentence in December 2005 and was released on
licence on 1 December 2006. One of the conditions of his licence was that he
must live at an address agreed with the probation service but the man failed
to comply with the requirement. He was subsequently instructed to report to
an approved premises (accommodation provided and managed by the
probation service) in mid February, but failed to arrive. As a result, his
probation licence was revoked, and he was returned to prison to serve the
remainder of his sentence.
29. Whilst on licence the man committed further offences and appeared at
Croydon Crown Court late March 2007, where he received an additional two
years imprisonment to be served at the same time as his existing sentence.
The man expected to be released from custody in May 2008.
30. The man arrived at Chelmsford in October 2007, having been in custody at
HMP High Down, Belmarsh, Littlehey, Edmunds Hill and Bedford. Throughout
his sentence, he was identified as at serious risk of harming himself. He
would frequently attempt to hang or strangle himself and was seen to try and
bite the veins in his arms. As a result he was often monitored on an ACCT
plan. In 2006, staff at High Down noted that his “risk of death [from self-harm]
was extremely high”. Because of this risk, the man was often monitored
constantly by staff. (The prisoner remains within eyesight and within a
suitable distance of the member of staff at all times, such that immediate
action can be taken if they attempt to self-harm.) The man complained of
hearing voices that told him to kill himself. He was often placed in the
healthcare centre of the prisons because of his mental health issues and risk
of self-harm.
31. The suicide prevention officer at Chelmsford manages the ACCT training and
implementation. She first became aware of the man when she was
telephoned by staff at Bedford prison and notified of his impending arrival.
She was told that the man had been in their healthcare centre with an open
ACCT document and a constant watch. She was also told that the man
wanted a move to Chelmsford because he felt that it would be closer to his
family and easier for them to visit. The suicide prevention officer understood
that Bedford thought the man would go to normal location on a wing rather
than healthcare on arrival at Chelmsford. The man had apparently said that
he wished to get a job at Chelmsford and take a full part in the regime. This
was reflected in the ACCT transfer information provided by Bedford prison.
The man attended his ACCT review on 16 October before leaving Bedford for
Chelmsford. He said he had no thoughts of self-harm and was looking
forward to the move as he would be nearer his family. The ACCT plan was to
observe and interact with the man hourly.
32. It was highlighted on the man’s Prison Escort Record (PER), which
accompanied him on his transfer from Bedford to Chelmsford, that he had
drug related convictions and that he was manipulative and a prolific self-
10
harmer. Warning markers on the Police National Computer (PNC) showed
that he concealed items to self-harm, was suicidal and had previously bitten
the veins in his arm.
33. When he arrived at Chelmsford, the suicide prevention officer met the man on
the induction wing and subsequently in healthcare. She found him to be an
engaging, likable person who was always pleased to see her. He was moved
onto the induction wing (E wing).
34. It was noted on the man’s Inmate Medical Record (IMR) at Chelmsford that he
had transferred from Bedford and had a history of mental ill health and self-
harm. He was being prescribed Chlorpromazine. It was recorded that the
man had been unable to cope following his brother’s recent suicide and
wanted to be at Chelmsford to be nearer his family. The man said he had no
thoughts of suicide or deliberate self-harm. It was recorded that he had good
eye contact, and was very talkative with good, positive, forward looking
conversation. An urgent referral was made to the doctor and Mental Health
Team (MHT).
35. A prison officer spoke to the man the following day as part of his ACCT
review. The man said he had thoughts of killing himself when he looked at his
dead brother’s photograph. He said staff at Bedford told him he would go
straight to healthcare at Chelmsford. The man was moved to healthcare later
that day, where he was to be monitored constantly. It is recorded in his
medical record that he was feeling unwell because of his brother’s recent
suicide. The notes record that the man was not having hallucinations, and
there were no physical concerns. He was referred to the Mental Health
Team. It was noted in his medical records that, at 1.00am on 17 October, the
man shouted “Nurse, I am hearing voices” but could not explain what the
voices were telling him to do.
36. On 18 October, another prison officer observed the man as part of the
constant watch. The man reiterated that he had been unable to cope
following his brother’s recent death and the death of his baby the previous
year. He said he harmed himself because of auditory hallucinations (hearing
voices), in which a male voice told him to kill himself, usually at night time. He
said that Bedford prison did not understand him and did not let him see
psychiatrists when he wanted.
37. The man appeared to the officer to show no signs of visual or auditory
hallucinations. He had good eye contact and was happy to discuss various
topics. He said he could be quite impulsive when directed by the voices and
could be directed at anytime to hang himself. With his consent, the man’s
blankets were exchanged for non rip blankets. It was decided that the man
should remain on a constant watch in healthcare and see the psychiatrist.
38. The man was seen by a psychiatrist on 19 October for his psychiatric review
following his transfer to Chelmsford. The psychiatrist noted the man’s history
of mental health problems and previous attempts to harm himself. He
11
directed that the man remain on constant watch and receive the same
medication.
39. The psychiatrist saw the man again on 22 October when he noted that there
had been no “untoward incidents” but that the man still complained of hearing
voices. The psychiatrist recorded that the man wished to go to normal
location on one of the wings but that he had also admitted that he might harm
himself if not on constant watch. The psychiatrist concluded that the man
should remain on constant watch and that his medication should be changed
from Chlorpromazine to Olanzapine (both antipsychotic drugs).
40. The man’s ACCT plan was reviewed in healthcare on 23 October, with the
man, a psychiatric nurse and a different prison officer present. It was decided
that the man should remain on a constant watch and under the care of the
Mental Health Team. He requested the papers for a move to another prison.
On 24 October, the man threatened a healthcare officer and threatened to
smash up his cell. The man said he wanted to see his children but knew that
he was not allowed.
41. The man was assessed by a second psychiatrist on 26 October. The second
psychiatrist recorded in the man’s medical records:
“In my opinion [the man] has a long standing mental disorder in the
background of mild learning disability and as a consequence as has
been reported on a number of occasions, he is most likely while in
HMP Chelmsford to continue to demonstrate impulsive explosive
behaviour with marked propensity towards committing acts of
deliberate self-harm on a very frequent basis. Therefore I
recommend that [the man] remains under constant observation in a
safe environment and not allowed any objects that can be used by
[the man] as a weapon for self-harm or harm to others.”
42. A further ACCT review took place on 27 October with the man, the officer who
had been present at the review on 23 October and another officer present. It
was decided that the man should remain on a constant watch.
43. On 29 October, the man was seen by the second psychiatrist. He was moved
to a cell with closed circuit television, although the reasons are not recorded,
and remained under the care of the Mental Health Team. It was noted that
the man remained without insight and was quite impulsive in manner. The
following day the man attended another ACCT review, and it was decided that
he should remain on a constant watch. At his ACCT review on 31 October, it
was noted the man had declined a shower and a telephone call. When asked
why, he said “I just feel tired”. It was decided that the man should remain on a
constant watch under the instruction of the Mental Health Team.
44. A further ACCT review took place on 1 November and it was noted that the
man had had a quiet day. He had used the telephone and remained on a
constant watch. The man was desperate to be removed from safe conditions
(this is when the prisoner’s bedding and clothing are replaced with items
12
made from material which cannot be ripped and therefore used to self-harm).
The following day, the man was seen by the first psychiatrist, as part of his
ACCT plan. It was decided that the man had settled and that observations
should be reduced from constant to hourly. He was moved to a new room
with a television. The review team were hopeful that, if he settled, he could
move to C Wing.
45. The man was seen again by the first psychiatrist four days later on 5
November as part of his ACCT plan. It was noted that the man remained
settled. He heard no voices and had no thoughts of self-harm. He was keen
to be transferred to F wing, to work and be occupied. The man mentioned a
possible move to HMP Belmarsh as this was closer to his family. His
observations were reduced to three conversations a day and hourly
observations at night.
46. As the man appeared to settle, he was moved to F wing on 8 November.
However, at his ACCT review later in the day, the man threatened to harm
himself unless he went back to healthcare. At 9.00pm, he told staff that he
was hearing voices telling him to harm himself. It was recorded in his on-
going prisoner record that at 9.25pm he rang his cell bell, threatened to rip a
sheet and self-harm. At 9.40pm, after ringing his cell bell again, he said that
he would smash his television and also said he had spat his medication down
the toilet. Ten minutes later, he rang his cell bell as he had cut his arms with
a razor blade. The man was asked to pass the blade under the door but said
he had swallowed it. He said that he was not allowed to see his children, that
his brother had hanged himself and that things were getting on top of him.
The Night Orderly Officer (the officer in charge of the prison overnight)
attended and entered the cell at 10.17pm with staff who cut a ligature from the
man’s neck made from his shoe laces. The orderly officer made the decision
to place the man on a constant watch in strip conditions, which meant that the
man was placed in a gown designed to minimise the risk of harming himself.
47. The man had managed to hide a blade, which he used to cut his arm. He
subsequently agreed to place the blade on a table where both he and the
officer could see it. He returned to healthcare the following day, where he
remained in strip conditions and on constant observations. He was seen
again by the first psychiatrist, who recommended that the man remain in
these conditions. On 10 November, the man was spoken to by a member of
the Mental Health Team. She noted that the man was settled in his mood and
that he had harmed himself as he wanted to move closer to his relatives. The
man said that he had always been impulsive and ‘did not think’. The member
of the Mental Health Team discussed alternatives to self-harm, such as
talking to staff when he found it difficult to cope. The man said he thought
about his children’s reactions should anything happen to him. It was decided
that the man should remain on a constant watch on an open ACCT.
48. The man was assessed by the two psychiatrists, a doctor, the member of the
Mental Health Team and the psychiatric nurse on 12 November, and they
decided that he was to remain in strip conditions. The Mental Health Team
arranged therapy with the man. The man was more positive at his ACCT
13
review on 13 November, and he said that he would like to come out of safe
conditions and off constant watch. He said he would not harm himself as his
brother died recently and he had more sense than to do so himself. The man
was advised that a decision would not be made until he had been seen by a
psychiatrist. It was noted that his eye contact and conversation were both
good.
49. Whilst under constant watch on 15 November, the man told the nurse
watching him that he still had razors. At the man’s ACCT review the following
day he was seen by a psychiatrist and it was decided that he should remain
on a constant watch. At 4.45pm the man was seen by healthcare staff after
he claimed he had swallowed a razor blade. He was lying on his bed
attempting to be sick. When asked why he had swallowed a razor, he said he
wanted to be with his little brother who was dead. The man was kept under
constant observations. The following day the man told staff that he had not
swallowed the razor blade and was just angry at being left in healthcare when
he wanted to go to the wing.
50. On 19 November, the man was seen by the first psychiatrist and another
ACCT review was completed. It was decided that the risk of self-harm
remained very high and that the man should be monitored in a cell with CCTV
and be allowed to have his own clothes the following day if his behaviour
remained good.
51. The man was seen by the second psychiatrist on 23 November who noted in
his medical records that he remained very settled and showed no signs of
distress. The man denied any intention of harming himself and said that he
was feeling “alright”. The second psychiatrist recommended a reduction in
the level of observation to hourly and that the man should be allowed his
normal clothing, at the Senior Officer’s discretion.
52. On 27 November, the man attended his ACCT review with the healthcare
senior officer, the healthcare officer who had attended the review on 24
October and the prison officer who had attended the reviews on 23 and 27
October. He had received news that his wife was visiting him and that an
aunt had passed away. It was noted that he had not recently self-harmed.
The man was seen by the Samaritans. On 3 December, he was seen by the
first psychiatrist who noted that he denied thoughts of self-harm, and was
keen to be transferred to Belmarsh or onto a wing.
53. The man went to the next ACCT review on 4 December with the healthcare
senior officer and the healthcare officer. It was noted that he was still doing
well. The man asked to be moved to an ordinary wing location and hoped for
a transfer to Belmarsh to be nearer his family. He had not made any further
attempts to harm himself.
54. At an ACCT review on 11 December with the officer who had attended the
review on 27 November and another officer, it was noted the man had settled
in healthcare with no negative incidents or thoughts. He was mixing well with
others. The man said he was desperate to go to a London prison but was told
14
that this would be difficult because of a lack of space. The man said his
medication was not working.
55. The man had a psychiatric review on 17 December. It was noted that there
were no major concerns, and it was decided to increase the dosage of his
medication and that he should remain in healthcare.
56. It was noted on the man’s ACCT plan on 20 December that he continued to
do well. He did not complain or request anything, but did ask about his prison
move. There had been no recent acts of self-harm or suicidal threats. It was
agreed that the man should remain on an ACCT for a further review. Two
days later the man was again present at his ACCT review with the two officers
who had attended the review on 11 December. It was noted that the man
continued to do well and mix with others. He asked when he would be going
back to the wings. He said he had no negative thoughts.
57. A psychiatric review was carried out on 24 December by the first psychiatrist.
The man said he had no ideas of self-harm and that his medication had
helped, although he was hearing voices at night. It was decided to discharge
the man to the wing, and he was moved to E wing the following day, where he
was to be observed by staff every hour. At an ACCT review held immediately
after the move, he said he felt “okay” but would prefer to move to B wing. He
had no thoughts of suicide or self-harm and said he would speak to staff and
Listeners if he was feeling low.
58. The psychiatric nurse told my investigator that the man’s release date was
nearing and he wanted to go to a London prison to improve his contact with
his family. The man had said that he had wanted to come to Chelmsford as it
was nearer London and was hoping his next move would be a London prison.
The man wanted to leave healthcare and be located on the wing, and this was
discussed with him.
59. On Christmas Day, staff found a noose in the man’s cell and, because of his
history, the psychiatric nurse readmitted him to healthcare for assessment.
The man said he had the ligature because he was put on E wing rather than B
wing, which is where he wanted to be. The man apologised and blamed the
system for not putting him on B wing.
60. Three days later, on 28 December, the man went to his next ACCT review
with the officer who had carried out constant observation duties on 18 October
and the healthcare officer. He was settled although he claimed to have been
bullied on the wing. My investigator could find no evidence that the man’s
allegation of bullying had been investigated further. It was noted that the man
did not cope well on ordinary location, but did manage and mix in smaller
groups. It was decided that he should remain on an ACCT document until
seen by the psychiatrist.
61. The man was seen by both psychiatrists on 31 December and said that he
would now like to go to B wing and promised “I won’t do it again”. It was
decided that the man should remain in healthcare.
15
62. On 4 January, the man attended his ACCT review with the healthcare senior
officer and two prison officers. It was noted that he remained settled and well.
He wanted to return to a prison wing and was told that he would be further
reviewed on 7 January by the Mental Health Team. The first psychiatrist saw
the man on 7 January and decided he could go to B wing as he wanted to do
an Enhanced Thinking Skills course. The psychiatrist noted that the man was
“determined to remain on normal location to get on with his sentence”. The
man remained settled, and was not hearing voices. It was noted at the man’s
ACCT review with the healthcare senior officer, an officer and the first
psychiatrist that it might be prudent to place the man in a shared cell –
preferably with someone he knew - as he was not a danger to others but more
to himself. No member of B wing staff was present at the man’s ACCT review
on 7 January.
63. The healthcare senior officer knew the man well, attending a number of his
ACCT reviews. He was aware that he had been transferred from Bedford and
had been on a constant watch. The senior officer said the man was well liked.
Early on in his time at Chelmsford, the man talked to the senior officer about
wanting a move to High Down to be closer to his mother’s home, and about
the death of his brother. Some months later, the senior officer recalled a
conversation with the man during which he said he wanted to go on the wing.
The senior officer asked the man if he was sure about this, because he could
stay in healthcare if he wanted to. The man said he had asked the doctor,
who said he could go to the wing and that he wanted to go to B wing as he
knew some prisoners there. Early January, the senior officer arranged for the
man to go to B wing. He asked him if he still wanted to transfer to High Down,
and he said that, as he was being released in May, he was happy to stay.
During his interview with my investigator, the senior officer said that in the
ACCT case reviews he was involved in with the man, all parties to the
document were consulted and contributed but did not necessarily attend the
review.
64. Another prisoner at Chelmsford knew the man from outside prison. They got
on well together and had adjoining rooms in healthcare. The prisoner said in
interview with my investigator that they were both on ACCT plans. He last
saw the man in the late afternoon of 8 January, when he came to his cell and
said that he was going to B wing. He said he was looking forward to the move
and would try to get a single cell and meet up with the prisoner on B wing
when he too was discharged from healthcare.
65. The man was accompanied to B wing in January by two movement officers,
who knew he was on an ACCT and was to be checked every hour. During
her interview with my investigators, one of the movement officers explained
that, on arrival on B wing, she had looked at the man’s last ACCT review,
which had been completed in healthcare. She noted that it did not specify
whether the man should be placed in a single or double cell when he arrived
on B wing. The man asked that he be given a single cell. The movement
officer rang healthcare and spoke to the healthcare senior officer, who told her
that the man could be placed in a single or double cell. In interview, the
16
senior officer said that he told the movement officer that the man could
occupy a single cell as he had been in one in healthcare. The movement
officer informed the senior officer on B wing who allocated a single cell on the
third landing: B3.31. The man gave the movement officer no cause for
concern or any indication that he intended to take his life.
66. It was noted in the man’s B wing history folder by a B wing officer that,
although the man was nervous about leaving his cell for association, he came
out and associated with other prisoners. The B wing officer spent at least 15
minutes helping the man to fill out application forms for education and work.
The man was later locked in his cell for the night.
67. A new officer who had been working at Chelmsford since December,
commenced his first ever night duty that evening on B wing. He was the only
officer on the wing and had sole responsibility for the care of the prisoners.
He had had no formal instruction or specific training for night duties. As part
of his core prison officer training, the officer had received comprehensive
training about the ACCT document and procedures. He was familiar with the
system and was comfortable working with prisoners on ACCT documents.
There were 132 prisoners on the wing, four of whom were monitored under
the ACCT arrangements.
68. At 9.25pm, the officer on his first night duty answered the man’s cell bell. The
man said he was hearing voices. The officer knew the nurses had recently
left the wing and asked the man if he had taken his medication. The man said
that he had been given medication to help him “deal with the voices”. The
officer advised him to sit down and drink some water and his medication
should suppress the voices. The man said he would do this. The officer
thought that the man seemed “down and sad” so he asked the man what the
voices were telling him to do, and the man replied that they were telling him to
kill himself. The officer told the man that he did not want him to kill himself
and said that there would be other people who did not want him to kill himself
either. With this, the man smiled and sat down. The officer asked the man if
he would be okay whilst he carried out his duties. The man nodded and said,
“don’t forget me” and the officer told him he would return in a while.
69. The officer then checked on other prisoners on the wing who were on ACCT
documents. He returned to the central office and responded to another cell
bell which was activated. As he opened the cell flap he saw that one of the
prisoners occupying the double cell had made some superficial cuts to his
wrist. The officer radioed a code 2 (meaning there was a non-life threatening
situation needing medical assistance) call for assistance but did not enter the
cell. He advised the prisoner to press a shirt on the wounds to stop the
bleeding. Whilst he was waiting for assistance to arrive he returned to check
on the man.
70. The officer reached the man’s cell at 10.00pm. Upon opening the observation
flap he noticed that the cell light was now off, and he saw the man with a
ligature made from bedding material tied from the cell window bars attached
to his neck. The officer radioed his position and a code 1 (meaning there was
17
a medical emergency) to the control room. He broke the sealed pouch
containing the cell key, unlocked the door and went inside, where he
supported the weight of the man’s body. Very soon afterwards, the senior
officer on duty, an officer, followed by a nurse, who had arrived on the wing to
deal with the previous emergency.
71. The senior officer on duty that night said that on the evening/night of 8
January he was the Night Orderly Officer in charge of the prison with the radio
call sign Oscar 1. During the evening he received a code 2 radio call telling
him a prisoner on B wing had cut his wrist. He went with the nurse to B wing
and, whilst they were on their way there, heard a code 1 call on his radio. He
went to the man’s cell and went inside, immediately behind the officer who
had also responded to the code 1 call. The officer on his first night duty had
taken the man’s body weight and the other officer cut the ligature from his
neck. The officers laid the man on his back on the cell floor. The two officers
started resuscitation and were joined by the nurse, who asked the senior
officer to collect some more oxygen from the wing as her cylinder was not
working. When he returned to the cell, the officer who had responded to the
code 1 call was carrying out chest compressions whilst the nurse was
administering oxygen.
72. The nurse said in interview that she had known the man as he had been in
healthcare for some months. She had a good relationship with him and they
often shared a joke. She described him as a very personable young man,
who had mental health problems. On the day of the man’s death, the nurse
started her shift in healthcare just before 9.00pm. (Nurses on night duty at
Chelmsford do not routinely carry keys, as a safety and security measure
against hostage taking and attack. They are therefore escorted by Oscar 1,
the Night Orderly Officer, or his deputy, Oscar 2, who both carry keys to areas
of the prison where prisoners may require treatment.)
73. The nurse noticed from the man’s clinical records that he had been moved to
B wing that day and had settled. She was not surprised that he had been
moved from healthcare as she said that he was desperate to go back to the
wing. He had been asking for quite some time because it was something he
was working for. She said he was very positive and looking forward to being
released.
74. Later that evening the nurse was asked to attend B wing as a prisoner had
self-harmed by cutting himself. She was collected from healthcare by Oscar 1
and, as he was collecting her, a further message was received over her radio
for a code 1 on B wing.
75. The nurse said that she arrived at the man’s cell within minutes of the call, just
as he was being cut down. She immediately called for an ambulance and
checked him over, establishing that he had no pulse and was not breathing.
She noticed he had a deep laceration around his neck. The nurse started
resuscitation by putting an airway in the man’s mouth and giving oxygen from
a brand new bottle which she initially found difficult to turn on. She was
18
assisted by the two officers carrying out chest compressions until the arrival of
the ambulance staff.
76. The ambulance arrived at Chelmsford at 10.15pm and the paramedics
reached the man’s cell at 10.19pm. The defibrillator (this is a machine that
can restart the heart by giving an electric shock in some cases of cardiac
arrest) was placed on the man but no heart rhythm was detected. The man
was taken to hospital at 10.40pm where he was pronounced dead.
77. The suicide prevention officer said she was saddened to receive a telephone
call informing her of the man’s death as she had got to know him well through
speaking to him and attending his ACCT reviews. The healthcare senior
officer learnt of the man’s death the following day and said he was absolutely
devastated.
Post Mortem
78. The post mortem concluded that the man died as a result of hanging. The
pathologist was satisfied that there was no evidence of either third party
involvement or natural disease contributing to the man’s death. The
toxicology report found no evidence of either alcohol or drugs (other than
those prescribed to the man) in his blood.
Contact with the family
79. A governor went to the man’s grandmother’s address in South London in the
early hours of the day following his death. He arrived and liaised with the
local police before breaking the news of the man’s death. The prison offered
to pay the man’s funeral expenses and arranged for his partner to visit to
Chelmsford and the cell where the man was found. The prison also arranged
for other family members to attend the prison. The governing governor
subsequently attended the man’s funeral.
Prisoner and staff welfare
80. Staff and prisoners felt generally well supported after the man’s death.
Members of the Care Team and Chaplaincy visited the prisoners on the wing
and offered their support. The prisoner who knew the man said that the news
of his death was sympathetically broken to him and he was monitored by staff
and members of the chaplaincy team. The suicide prevention officer said in
interview that Chelmsford’s contingency plan following a death in custody was
followed and all prisoners on ACCT documents in the prison were reviewed.
81. The governing governor spent time talking to affected members of staff on the
day the man died. A debrief meeting was held several weeks later with
members of staff who had been involved. It appears that a hot debrief (a
meeting held very shortly after an incident for staff immediately involved) was
not held in the hours that followed the man’s death.
19
ISSUES CONSIDERED IN THE INVESTIGATION
The man’s clinical care
82. A review of the clinical care the man received at Chelmsford was undertaken
by a clinical reviewer. One of the issues considered by the clinical reviewer is
the standard of medical record keeping at Chelmsford. The clinical record
should reflect the care given to the man and so each entry should be legible,
dated and timed in order to follow care over the 24 hour period. Each entry
should be completed with a signature (and if the first entry in the record, the
surname and title should also be printed). The clinical reviewer found the
man’s record to be of poor quality in this respect. Whilst all entries have been
dated, not all have the time recorded and although signed, not all surnames
are legible. Furthermore, on some days no entries were made and entries
made by health care assistants have not been countersigned by qualified
staff. The Ombudsman made a recommendation about the standard of
record keeping in a report on another death in custody at Chelmsford that has
just been published and this recommendation has been accepted. I do not
propose to repeat that recommendation here.
83. Chelmsford currently does not have an integrated clinical record system in
operation which means that treatment and action undertaken by healthcare
staff and the Mental Health Team are noted on separate records. There does
not appear to be a mechanism for sharing information contained in these
records. The implementation of an electronic system would greatly improve
the quality of the clinical record. The Head of Healthcare has told my
investigators that she anticipates that an electronic system will be introduced
by the end of 2009.
Bullying
84. The man complained of being bullied when he was briefly located on E wing.
Chelmsford has a comprehensive violence reduction policy. The suicide
prevention officer told my investigators that all information about bullying is
recorded in a Security Information Report (SIR) which is passed to the
security department of the prison. The information is then passed to relevant
staff to deal with. However, my investigators could find no documentary
evidence that the man’s claim he had been bullied had been investigated
further or recorded on an SIR.
The Governor should remind staff that any allegation of bullying must
be properly recorded, in line with the violence reduction policy.
Assessment, Care in Custody and Teamwork
85. I believe that the man was carefully supported and managed under his ACCT
plan. The documentation was generally completed well, with detailed
comments and observations recorded and clear action plans. He was
monitored on ACCT for the majority of his prison sentence and at a number of
other prisons. My investigator reviewed the paperwork relating to the man’s
20
time at other prisons and found that they too generally had completed the
ACCT documentation appropriately. I am satisfied that the man received the
same standard of care whilst at Chelmsford as he did at other prisons. I am
pleased to note that the man was treated with respect and kindness by staff at
Chelmsford, who worked hard to respond to his needs and keep him safe.
86. However, the healthcare senior officer said that in the case reviews he was
involved with, whilst all parties to the review would have been consulted
before the ACCT document was completed, they may not have been present
at the review. This is not reflected in the ACCT document.
The Governor should remind staff that those participating in an ACCT
review should, wherever possible, be present. The paperwork should
clearly reflect who is present and who has been consulted or made a
written contribution.
87. The clinical review also considered the quality of the man’s ACCT document.
The reviewer found that on two occasions ACCT reviews did not take place
on a daily basis as scheduled. In one case, there were four days between
reviews and in the other case two. Whilst in this case, the man had been on
ACCT for a long time and I am satisfied the timing of the ACCT reviews did
not affect his care, in other cases it may be important.
The Governor should remind staff that ACCT reviews should take place
as scheduled.
88. The last ACCT review held for the man took place early January 2008 when
his discharge from healthcare to B wing was agreed. According to the
document, those consulted included the man and healthcare staff. It does not
appear that a member of B wing staff was asked to attend the ACCT review
as part of a continuous ACCT plan.
The Governor should remind staff that when a prisoner on an ACCT plan
is to be relocated, a staff representative from the receiving wing is
present for the ACCT review.
89. The man’s family asked whether he was aware of the death of another
prisoner at Chelmsford on 25 December, and whether he received any
support afterwards. There had, in fact, been two deaths at Chelmsford while
the man was there. The suicide prevention officer said that all prisoners on
ACCT documents were reviewed following deaths in custody. The man’s
ACCT documentation clearly indicates that he was reviewed on 27 November
in line with the prison’s post suicide policy. The man’s ACCT was also
reviewed at 10.00am on 25 December but it is not clear if this was as a result
of the death of a prisoner that day. The man said he was not feeling low or
suicidal but that he would speak to staff or ask for a Listener if he needed to. I
am satisfied that the man continued to receive support from staff at the prison
around the time the two other prisoners died. However, later on 25
December, the man was found with a ligature and moved back to healthcare.
A further case review should have been held, in line with PSO 2700.
21
Discharging the man from healthcare
90. On 8 January, the man was discharged from healthcare and transferred to B
wing. The In Patient Discharge Policy for Chelmsford outlines a number of
procedures which ensure that prisoners receive the continuing care they need
after discharge. The policy is intended to be flexibly applied according to the
individual needs of the patient. However, the policy states that “a discharge
care plan shall be drawn up”. My investigator could find no evidence in the
paperwork provided that a discharge care plan had been drawn up for the
man.
91. The man was escorted to B wing by two movement officers. The man had
spent a considerable amount of time in healthcare and on an ACCT and had
previously attempted to self-harm when transferred to the wings. A written
summary of care to fully inform staff on the receiving wing of the prisoner’s
history would be more appropriate than a verbal handover when transferring
prisoners from healthcare to the wings.
The Head of Healthcare and the Governor should ensure that healthcare
staff provide a written summary of care when any prisoner is being
transferred from healthcare to the wings. A discharge care plan should
also be drawn up, in line with the In Patient Discharge Policy.
The decision to place the man in a single cell on B wing
92. The first psychiatrist saw the man on 7 January and considered that he was
well enough to be discharged from healthcare as he had been settled with no
thoughts of suicide or self-harm for over a week. For some time, the man had
been requesting a move to normal location. He particularly wished to be
placed on B wing where he said he had friends. The man remained on
healthcare until the following afternoon when he was transferred to B wing on
an ACCT plan with hourly observations. Before leaving healthcare he was in
a positive mood. He told another prisoner that he was going to B wing and
was going to try and get a single cell.
93. At the man’s ACCT review on 7 January, it had been noted that he might be
better placed in a double cell – preferably with another prisoner he knew. A
single cell was available on B wing and the officers escorting the man
telephoned the healthcare senior officer to establish if a single cell would be
suitable. The senior officer said it was, and his rationale was that the man
had been in a single cell in the healthcare, had been discharged and was on
hourly self harm observations.
94. The suicide prevention officer said in interview that the man had always
expressed a preference for a single cell and she felt that he would have found
sharing a cell quite difficult. The suicide prevention officer emphasised that
decisions about the best location for prisoners on ACCT forms had to take
account of the prisoner’s preferences alongside recommendations made as
part of their ACCT document. The man was allocated a cell on the third floor
22
of B wing and the wing office is located on the ground floor. The suicide
prevention officer explained that each landing on the wing is patrolled
throughout the night. She felt that, given the man was on hourly observations
when he arrived on B wing, the allocation of the cell on the third floor was
appropriate.
95. I am satisfied that staff gave proper consideration to the man’s best interests.
The healthcare senior officer knew the man well and, it seems, weighed up
the potential risks in placing him in a single cell against the man’s wishes to
have a single cell and the fact that he had been discharged from a single cell
in healthcare on reduced observations. I believe that healthcare staff at
Chelmsford kept the man at the centre of all decisions made about him, and
this is to be commended.
96. The man’s family wished to know whether he had a personal officer when he
was moved to B wing. Chelmsford’s policy is that personal officers are
allocated as soon as a prisoner arrives onto a wing and so the man would
have been allocated a personal officer early January. However, given the
short amount of time that the man spent on B wing before his death it is likely
that he had not yet met his personal officer.
Staff contact with the man on the night of a day in January
97. The officer on duty overnight on 8 January, a newly qualified officer,
commenced his ever first night shift on B wing that night. Although he had
undergone prison officer training he had not had any specific training for night
duties. He was responsible for the care and custody of 132 prisoners on B
wing, four of whom were on open ACCT forms. He spoke with the man at
9.25pm when he responded to his cell bell. The man told him he was hearing
voices telling him to kill himself. The officer reassured him and told the man
that he would be back to see him in a while.
98. The officer was asked, in a follow up interview with an investigator, if he had
considered contacting either the Night Orderly Officer or healthcare staff for
advice following his conversation with the man. He explained that whilst 25 to
30 minutes had passed between the man ringing his cell bell at 9.25pm and
the other prisoner self-harming in a nearby cell, he had been busy checking
other ACCT prisoners and answering cell bells and so he had not had time to
think about contacting the Orderly Officer or healthcare staff. He said that he
would have felt confident in doing so had he needed to.
99. The officer said that he did not offer the man a Listener or the opportunity to
use the Samaritans phone that night. Although the man had seemed down
and sad, the officer thought he seemed quite calm and not “at the end of his
tether” and so he had not thought it necessary. Despite not having received
specific training for night duty, the officer told my investigator that he felt
confident about accessing Listeners during the night. He said that he thought
prisoners were made aware of the availability of both Listeners and the
Samaritans phone during their induction at the prison and so he might have
expected the man to ask for one or other service if he felt in need. Whilst this
23
may sometimes be the case, staff should not assume that a prisoner will know
how to or feel confident in asking for access to such services.
100. With the benefit of hindsight, the officer might have taken additional action
after his conversation with the man. He explained how he made his decisions
on the basis that the man was not outwardly displaying very concerning
behaviour. He felt that the ACCT procedures under which the man was being
monitored would be sufficient to support him through the night. In this case, I
believe the officer could have offered the man the opportunity to speak to a
Listener or use the Samaritans phone. While I make no formal
recommendation, the Governor may wish to remind staff that prisoners should
be offered the services of Listeners and the Samaritans as appropriate.
The Governor should ensure that staff undertaking night duties receive
appropriate training covering the specific responsibilities and duties
involved. The Governor may also wish to consider adopting a
mentoring scheme for new officers commencing night duty for the first
time.
Staff response to finding the man hanging
101. The officer checked the man at about 10.00pm after having radioed for
assistance for the prisoner who had self harmed in a cell nearby. On looking
through the observation panel of the man’s cell, he discovered him hanging.
The officer again radioed for urgent assistance before entering the man’s cell
using the cell key contained in his sealed pouch, shortly followed by other
staff.
102. Upon discovering the man, staff acted quickly and efficiently in entering the
cell, cutting him down, radioing for an ambulance and commencing
resuscitation. Sadly the man was pronounced dead upon his arrival at
hospital.
Night nurses’ access to keys
103. A clinical reviewer noted that healthcare staff do not carry keys for the
establishment at night, and in the event of an emergency must await the Night
Orderly Officer who escorts them to the scene of the emergency. In the
man’s case, the orderly officer and nurse were already on their way to B wing
to respond to an earlier code 2 alert made by the officer. I am satisfied that, in
this case, there was no delay to the man receiving medical attention. I have
previously recommended to the Governor that healthcare staff should be
given emergency access keys during the night and so do not intend to repeat
the recommendation here. I am aware that this matter is still under
consideration.
24
Breaking the news of the man’s death to his family
104. The man’s family were informed of his death by a governor, who visited the
man’s grandmother’s address in South London at 4.00am on 9 January. The
family felt that the prison should have contacted them sooner.
105. Prison Service Order (PSO) 2710 sets out the procedure for informing next of
kin following a prisoner’s death, and this has been adopted by Chelmsford.
Following a death at the prison, the governing governor or deputy governor
appoints an operational manager to act as the Family Liaison Officer and
break the news of the death to family members. This can result in delays
(particularly when the death occurs during the night) as the appointed
manager will have to travel in to the prison, make sure they have as much
information as possible about what has happened and then liaise with local
police before travelling to the family member’s home. Where the death has
occurred during the night, the Family Liaison Officer will also consider whether
it is appropriate to visit the family in the early hours of the morning when they
may not have access to support.
106. Wherever possible, Chelmsford send the Family Liaison Officer and a
member of the chaplaincy team to visit the next of kin’s home to break the
news in person, and this is considered to be good practice. However, it can,
as illustrated above, lead to delays in the family being notified of the death. It
is my view, therefore, that the five hour delay between the man being
pronounced dead in hospital and the governor breaking the news to his family
was not unreasonable.
Contacting the Independent Monitoring Board
107. My investigators interviewed a member of the IMB and who was also the duty
member for the night of the day of the man’s death. PSO 2710 requires that
the prison notify the IMB of a death in custody. The IMB member interviewed
said that a colleague (not the duty member) was telephoned by the prison at
about 10.00pm on the day of the man’s death and was told that a prisoner
was being resuscitated but that the IMB did not need to attend. The IMB
member received another call at about 10.45pm to say that the prisoner was
being transferred to the hospital. The prison did not make contact with the
IMB to let them know that the man had subsequently died. In fact, the IMB
only became aware of the man’s death when another member arrived at the
prison on the day following the day of the man’s death and saw the notice to
staff at the gatehouse. Subsequent investigation by the IMB revealed that
there had been some confusion in the prison about whether the IMB had been
contacted and which member should have been contacted.
The Governor should remind staff that the IMB must be contacted when there
is a death in custody.
25
RECOMMENDATIONS
1. The Governor should remind staff that any allegation of bullying must be
properly recorded, in line with the violence reduction policy.
The Prison Service has accepted this recommendation.
2. The Governor should remind staff that those persons participating in an ACCT
case review should, where possible, be present for the review. The
paperwork should clearly reflect who is present at the review and who has
been consulted or made a written contribution.
The Prison Service has accepted this recommendation.
3. The Governor should remind staff that ACCT reviews should take place as
scheduled.
The Prison Service has accepted this recommendation.
4. The Governor should remind staff that where a prisoner on an ACCT form is
to be relocated, a staff representative from the receiving wing is present for
the ACCT review.
The Prison Service has accepted this recommendation.
5. The Head of Healthcare and the Governor should ensure that healthcare staff
provide a written summary of care when any prisoner is being transferred
from healthcare to the wings. A discharge care plan should also be drawn up,
in line with the In Patient Discharge Policy.
This recommendation has been accepted.
6. The Governor should ensure that staff undertaking night duties receive
appropriate training covering the specific responsibilities and duties involved.
The Governor may also wish to consider adopting a mentoring scheme for
new officers commencing night duty for the first time.
The Prison Service has not yet responded to this recommendation.
7. The Governor should remind staff that the IMB must be contacted when there
is a death in custody.
The Prison Service has accepted this recommendation.
26