Individual at Styal

Investigation into the circumstances surrounding the
death of a woman
at HMP & YOI Styal in January 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
This is a report into the circumstances surrounding the death of a woman, a prisoner
at HMP Styal, in January 2009. She was found at approximately 6.30pm in her cell
having hung herself. The officer who discovered her called for assistance, and staff
and paramedics attempted resuscitation. She was pronounced dead by the prison
doctor. She was 36 years old. I offer my sincere sympathy and condolences to her
family and friends for their loss.
The investigation was carried out on behalf of the Ombudsman by my colleague. A
clinical review of the woman’s healthcare at Styal was undertaken by a clinical
reviewer on behalf of the local Primary Care Trust. I am grateful for his review. I
would also like to thank the Governor of Styal and his staff for their co-operation and
assistance. Particular thanks go to a duty governor for her help throughout the
investigation.
The woman had been in prison several times and suffered with drug addiction. She
had just begun a short sentence at Styal and arrived with symptoms of drug
withdrawal. She was withdrawing from drugs but staff did not consider her at risk of
harming herself. She was confined to her cell because staff believed that she had
brought drugs with her. While in her cell she hung herself.
The woman did not give any indication that she was likely to harm herself. She had
made plans for a visit and told staff of her desire to find somewhere to live.
However, she felt unwell due to the pain of her drug withdrawal and it is possible that
this led to her actions.
I make three recommendations.
This version of my report, published on my website, has been amended to remove
the names of the woman who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Prisons and Probation Ombudsman
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CONTENTS
Summary
The Investigation Process
HMP & YOI Styal
Key Findings
Issues
Recommendations
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SUMMARY
The woman was born in July 1972. She was arrested in January 2009, and
sentenced to 28 days in prison the following day.
Upon arriving at Styal, the woman went into the toilets with another prisoner. Staff
noticed cigarette smoke and followed the two women. They suspected her of
bringing drugs into the prison and confined her to her cell for the next 24 hours.
The woman was unwell due to withdrawing from drugs and considered the amount of
methadone she was given insufficient. Despite her discomfort, staff told my
investigator that they did not consider her to be particularly unwell compared to many
of the women in Styal.
The woman hung herself at some point between 5.15pm and 6.30pm in January.
She was found by an officer who immediately called for assistance. Cardio
pulmonary resuscitation (CPR) started quickly and continued until the paramedics
arrived and took over. The prison doctor declared that she had died. Prison staff
contacted her family and broke the news of her death.
The woman never gave anyone the impression that she might harm herself.
Although she was in discomfort due to withdrawing, the conversations she had with
staff included plans for the future.
I make three recommendations in this report. They include issues that the
Ombudsman has raised in other investigations at Styal. They relate to detoxification
and the issuing of Incentive and Earned Privilege (IEP) warnings.
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THE INVESTIGATION PROCESS
1. The investigation into the woman’s death was opened in January 2008 by an
investigator and the Deputy Ombudsman. They met senior managers at the
prison and collected the woman’s prison records. Notices of the investigation
had already been sent to the prison but no-one came forward in response.
2. The investigator wrote to the local Primary Care Trust requesting a review of
the woman’s clinical care in custody. The clinical reviewer was provided with
a copy of the medical records from the prison and relevant interview
transcripts.
3. The investigator and an Assistant Ombudsman visited Styal in March to
interview staff and prisoners. The investigator returned later in March to
conduct further interviews.
4. One of the Ombudsman’s family liaison officers contacted members of the
woman’s family. They felt strongly that she would never have intentionally left
her daughter. They described her as a strong person who had dealt with
difficult events in her life. They said she had spoken positively about the
future and intended to find somewhere for her and her daughter to live. The
family felt these were not the actions of someone who intended to take their
own life. They said that the only possible explanation was that she
experienced too much pain from withdrawing from drugs. Her family raised
the following issues:
(cid:127) How was her detoxification being managed?
(cid:127) She asked for more drugs to help her cope with the pain she was
experiencing whilst detoxifying. Why were they refused?
(cid:127) Why was it considered appropriate for her to have items which could be
used to harm herself?
(cid:127) Why was it considered appropriate to restrict the association of someone
undergoing detoxification?
(cid:127) Why was she not considered to be at risk of harming herself?
(cid:127) Why was her partner told of her death by telephone?
5. Following the publication of the draft report, the woman’s family responded
with their comments on the report. I have included reference to these views in
this version of the report. I hope this report offers some answers to their
questions.
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HMP & YOI STYAL
6. Styal opened as a women’s prison in 1962, having previously been a
children’s home and refugee centre. It increased in size by over 60 per cent
in April 1999 due to its transition to a local prison, and the closure of HMP
Risley. (A local prison serves the courts in the area, and generally only holds
prisoners for short periods of time.) It currently has a capacity of 460
prisoners and receives women from the North West and North Wales.
7. When women arrive at Styal they receive a Level A search. This is a fully
clothed rub-down search that includes the hair and facial area. It is followed
by a search with a wand that identifies any metal objects. A full search can be
authorised by any prison officer if they have intelligence that the prisoner may
be attempting to smuggle contraband into the prison and does not happen
routinely.
First Night Centre (FNC)
8. All women who come to Styal first stay in the First Night Centre (FNC). The
FNC is in a building called Oak House and it has space for 25 women in
single, double or four-bed rooms. Each FNC room on the FNC contains a
television, wardrobe, and a safe for locking away any valuables. There are no
safer cells on the FNC. (Safer cells have specially designed furniture and
fittings to reduce the number of ligature points.)
9. The regime on the FNC is more relaxed than on the regular wings. The
women are unlocked at 7.45am and largely remain out of their cells all day
apart from a short period over lunchtime. The women are checked hourly in
their cells throughout their first night. They stay in the FNC for at least 48
hours and a number of assessments, including those by healthcare and
substance misuse professionals, are carried out.
Incentives and Earned Privileges Scheme
10. Women at Styal who commit minor acts of indiscipline, exhibit anti-social
behaviour or fail to adhere to the required standards of behaviour or
performance can be issued with an Incentives and Earned Privilege (IEP)
warning. IEP warnings are issued at the discretion of officers and are used as
a tool to address prisoners’ behaviour. The warning operates under a
“tick/point system”. The women receive nine points each week and these
points can be added to or lost by the issue of positive (green) or negative
(pink) warning slips. One or more ticks can be received for each episode of
indiscipline. If a woman receives three ticks on one or two warning slips she
is punished by the loss of association for 24 hours which starts from 4.00pm
the following day. Loss of association means that women remain in their
room and are not allowed to mix with other prisoners. At the time of the
woman’s death the punishment had to be authorised by the group manager in
the relevant area. The women maintain their other privileges, such as
keeping the television in their cell.
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Independent Monitoring Board
11. Each prison has an Independent Monitoring Board (IMB) made up of
members of the community. The Board’s role is to ensure that the prison is
properly run and that prisoners are treated decently. Each Board produces an
annual report for the Secretary of State. The IMB has a large presence at
Styal with 17 members. The IMB representative that my investigator talked to
spoke of their good relationship with senior managers and the considerable
efforts made by staff to care for prisoners. The Board noted that the amount
of self-harm in the FNC had reduced, but commented that it was still an area
where the availability of drugs caused concern.
Her Majesty’s Chief Inspector of Prisons
12. Her Majesty’s Chief Inspector of Prisons inspected Styal in September 2008.
In her report she noted the challenging population in Styal, with over 33 per
cent saying they had felt depressed or suicidal, over 40 per cent with health
problems and over 50 per cent with drug problems. The report stated that
considerable effort was made to meet the challenges but “in spite of these
admirable efforts, the prison was not able to meet the scale and complexity of
need”. However, the report noted that “the Prison Service has yet to
recognise the level of resources needed to allow prisons like Styal to manage
and care for these women appropriately”.
13. The report described reception and first night arrangements as “mostly good”,
although it noted that “many women in our survey said they had felt unsafe on
their first night”. The report pointed out that, despite three further self-inflicted
deaths since the previous inspection, little had been done to develop action
plans. It commented on the well integrated drug strategies and early
intervention of the CARATs service.
14. The report stated that “some sanctions [under the Incentives and Earned
Privileges scheme] such as stoppage of association were implemented
without appropriate authority or review and decisions were not always based
on patterns of behaviour”. Staff were described as unsure of the system
which led to some inconsistencies and there was no evidence of management
checks to ensure consistency and fairness. The Chief Inspector said that
there were many examples where women lost association due to a single
episode of negative behaviour. The report recommended:
(cid:127) Prisoners should not lose association or receive other unsanctioned
punishments as a result of incentives and earned privileges warnings.
(cid:127) Regular management checks should be conducted to ensure that
warnings issued are fair and consistent.
Previous Ombudsman’s reports into deaths in custody at HMP Styal
15. Before the Ombudsman’s office was given the responsibility of investigating
all deaths in prison custody in April 2004, there were a series of six self-
inflicted deaths at Styal between August 2002 and August 2003. The
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Ombudsman personally investigated the last of these deaths and reviewed
the others. Between April 2004 and January 2009 when the woman died
there were three more self inflicted deaths at Styal. The office has also
investigated two natural cause deaths at the prison. The death of one of
these other women also occurred on the First Night Centre. She had not
been considered at risk of harming herself when she apparently took her life.
One of the other women who died had also lost her association on the day of
her death.
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KEY FINDINGS
16. The woman was born in July 1972 and had a daughter. She had a
longstanding drug problem which caused her to be arrested on numerous
occasions.
17. In January 2009, the woman was arrested by police at 9.55pm and taken to
the local police station. She was assessed at 10.14pm as being at medium
risk of harming herself and described as fit and well with no apparent injuries
or ailments. She told the police that she was a heroin and methadone user
and last used drugs at approximately 8.00pm. She said that she would cope
that evening but might need something in the morning to prevent her
withdrawing. She met a drugs worker at 11.54pm.
18. The woman was charged with theft and failing to appear in court. She was
seen by the doctor at 1.09am who confirmed that she was fit to be interviewed
and go to court, but noted that she may start to withdraw if she was detained
after 10.00am. Her risk of harming herself was noted as standard (the lowest
level). She left the police station at 7.14am to go to the Magistrates Court. A
police officer wrote that the woman had drug/alcohol issues on the Prisoner
Escort Record. She was sentenced to four weeks in jail and arrived at Styal
early that evening and was taken to the reception area.
19. The woman and another prisoner went straight into the toilets. (The prisoner
later told the police that they met on the transport van. The woman told her
that she had some drugs concealed on her that they could take when they got
to the prison.) When they were in the toilet cubicle, the prisoner told my
investigator that she rolled a cigarette because the woman said that she had
not smoked in several days. The woman removed a plastic ‘Kinder Egg’
holder that she had concealed. Staff were alerted to the cigarette smoke and
went into the toilet. An officer described what she saw:
“… as I went in the toilet they were smoking, I can’t remember if I saw
a cigarette now or not, I can’t remember without checking on
paperwork. But the woman had a ‘Kinder Egg’ in her hand, also her
trousers were near her knees, she was stood up with another prisoner
very close, obviously up to no good … “
20. A Senior Officer (SO), and two officers separated the women in order to carry
out a full search, which involved removing their clothes. The searches
revealed burnt foil and the plastic Kinder Egg holder. The SO told my
investigator that, given their behaviour, it was her belief that the women had
taken some drugs.
21. The prisoner was sure that she never actually saw any drugs in the toilet and
did not know what happened to them after staff entered. However, she
explained to my investigator that she was certain that the woman had some
drugs when she came to Styal.
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22. Bringing drugs into prison is a serious breach of prison rules. The staff
decided to issue the woman and the prisoner with an Incentives and Earned
Privileges (IEP) slip with three ticks on it. This indicated the offence was anti-
social and against prison rules. The usual process would be for the slip to be
collected by the IEP clerk who would pass it to the duty governor to decide the
appropriate punishment.
23. However, in this case the slip was never actually filled out. The first officer
believed the SO had done so, and the SO believed the opposite. The SO
decided that the woman should lose her association and stay in her cell for 24
hours, starting immediately. (This was not complete confinement as she
would be allowed out for an hour the following morning to collect her
medication and have a shower.) The woman would have contact with staff as
they made their routine checks of the First Night Centre (FNC). The SO
explained that the punishment was intended to protect the other women on
the FNC. As either the woman or the prisoner might have drugs concealed
within them, the officers decided that they could not allow them to mix with the
other women in case they passed drugs to them.
24. The reception process at Styal includes several meetings with prison staff to
assess immediate needs and risk. If a woman is initially categorised as not a
high risk to herself or others, she can be taken to the FNC. (This allows the
other assessments to be carried out in a quieter environment.) The first
officer undertook the woman’s Cell Sharing Risk Assessment (CSRA) after
the incident in the toilet and judged her to be at low risk of harming others.
25. The officer also completed the first part of the Immediate Needs Assessment
with the woman. She told the officer that she was on drugs but did not harm
herself. The officer described her appearance as: “just normal withdrawing,
nothing extreme. She answered the questions easily, she was not in pain or
anything”. The woman was taken to the FNC and the officer told the staff
about the punishment that she had incurred.
26. All women receive a healthcare reception screening when they arrive at the
prison. A nurse assessed the woman at approximately 8.00pm. She told the
nurse that she was a smoker and poly-drug user but did not intend to harm
herself. (Polydrug use is the use of more than one drug, often with the
intention of enhancing or countering the effect of another drug.) The nurse
recorded that her daily drug use was “3-5 bags of heroin daily, 60 mls of
methadone bought off the street, 20 mgs of Benzodiazepines and 3-5 bags of
cocaine daily”.
27. A drugs screen showed, that the woman tested positive for opiates and
cocaine. The nurse told my investigator that she seemed content and gave
no indication that she might harm herself. The nurse made a reference on the
computer: “no thoughts of deliberate self harm”. The woman’s blood pressure
was recorded as 99 over 81 which did not concern the nurse, although she
noted that her weight of 43kg was quite low.
10
28. The woman saw the prison doctor who confirmed her dependence on drugs
and prescribed a methadone stabilisation plan. (This is a regular daily dosage
of methadone aimed to remove the craving for opiates. A detoxification
prescription is different as it gradually reduces the methadone dosage to zero.
For women on short sentences, such as the woman, there is often insufficient
time for a detoxification prescription.) She was given 10mgs of methadone at
9.45pm that evening. This amount of methadone is normal at the start of a
methadone programme as it minimises any possibility of an accidental
overdose.
29. The woman was placed in cell 5 on the FNC. It is a double room but she was
the only occupant. (It was explained to the investigator that this was not
unusual as the location of the women depends on the number in the FNC.)
The first officer had already told the wing officer that she had lost her
association privileges for 24 hours. The woman telephoned a friend in the
evening and complained of withdrawing from drugs. The conversation
suggested that she asked her friend to smuggle drugs into the prison during a
visit the following day. She claimed that she was not given anything to
alleviate her withdrawal symptoms.
30. The woman slept until 5.30am the next morning and then asked for more
medication. She complained that she felt unwell an hour later. She was
given her breakfast and then allowed out of her cell at approximately 8.45am
for an hour’s association. She was given a second 10mgs of methadone at
9.05am. Whilst she was out of her cell, she saw the prisoner. The prisoner
told my investigator that the woman appeared to be withdrawing and had told
her that she felt really ill. The prisoner explained that the woman was a heavy
drug user and it was the prisoner’s personal opinion of detoxification that the
10mls would not have been sufficient to relieve her symptoms.
31. The woman met a CARATs worker that morning. (CARATs (Counselling,
Assessment, Referral, Advice and Throughcare) work with prisoners with drug
problems. The women are assigned workers who support them through their
sentence.) She told the CARATs worker that she was prescribed 10mgs of
methadone and felt very unstable. The CARATs worker said that, although
the woman said she felt ill, this was not uncommon among the women she
saw on the FNC. She explained that the woman expressed an interest in
working with the CARATs team, and was scheduled to have been taken on to
their workload during the next week.
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32. The woman also underwent a First Night Centre interview in the late morning
with the Probation Service Officer. He reviewed the CSRA assessment and
the woman repeated that she did not have any feelings of self-harm. She told
him that she had a daughter and explained the caring arrangements for her.
He had no concerns about her physical or mental well-being. He described
their conversation:
“I saw no issues at all with the woman. When we were actually talking
about the offence she actually said to me almost light heartedly that
another reason that she was in is that she’d done a breach by missing
an appointment. To which I said to her it was very unlikely that she
would be breached for missing a single appointment and almost
jokingly she kind of said ‘well OK it was three interviews that I missed’.
So she was almost, not light hearted and joking, but there was certainly
no suggestions of anything, any issues with her at all.”
33. The Probation Service Officer said that the woman made no comment about
the level of her methadone prescription to him:
“No, she just related that this was the dosage that she was on when
she came in. As I say she, you quite often get the feeling with some of
the lasses when they’ve come in if they’ve been on a higher dose and
they’ve come in, they’ve gone on a lower dose. They can be a little bit
shaky or a little bit upset but the woman didn’t show any signs of
anything like that.”
34. The woman received a Hepatitis B vaccination at approximately 10.50am she
refused a mental health assessment an hour later saying that she had no
mental health issues.
35. An officer found her in another woman’s room having a chat and locked her in
her room at approximately 11.00am. The woman had been out of her cell for
more than an hour because staff were busy with medication and day-to-day
tasks. She did not present any concerns and seemed to accept her loss of
association well. The officer remembered that she complied and immediately
returned to her room.
36. The wing officer saw the woman a number of times over the next few hours as
she completed various tasks on the FNC. The woman asked if she could
have a telephone call, and later said she felt ill and “10mls was not enough to
hold me”. The officer took her lunch up to her at 12.00pm. The woman asked
for help with her pin telephone application, and the officer explained the form
to her. (This is the method by which prisoners are allowed to make telephone
calls.) The officer told my investigator that although the woman looked as
thought she was withdrawing, this was not unusual on the FNC.
37. The officer told the Healthcare Assistant (HCA) that the woman felt unwell.
The healthcare assistant said that the woman would be given another 10mls
of methadone that evening. The officer went to see the woman to tell her and
the woman gave her the pin phone application and a letter. According to the
12
officer, the woman accepted the information about the medication calmly
although she did make another reference to 10mls not being enough.
38. The officer read the woman’s letter. (My investigator was told that all mail
from the FNC is read before it is posted.) The officer later had a call from the
security department who expressed concerns that, having listened to the
woman’s telephone conversation the previous evening, it was clear that drugs
were to be brought in on a visit. The officer believed that an under-lined part
of the letter might be a code relating to smuggling of drugs during visits. She
told the security department about her suspicions.
39. The woman spoke with one of the FNC orderlies through her door. (An
orderly is a prisoner who works in the prison.) The orderly remembered that
the woman looked ill and had asked her if she “could get her anything”. The
orderly assumed that this was a reference to illicit drugs, and told her that she
could not get her any.
40. The woman’s blood pressure was taken at 2.55pm by the HCA which was
102/68 with a pulse of 72. My investigator was told that these blood pressure
and pulse readings were within normal range for someone of the woman’s
lifestyle. (It was also noted that she was showing visual signs of withdrawal.)
The HCA went through a series of documents with the woman:
(cid:127) The first was the prison’s Substance Misuse Clinical Assessment. The
HCA explained that the document records the drugs (and amounts) that
the woman used in the community. It also covers various risk factors
concerning their drug usage.
(cid:127) Second the Opiate Withdrawal Monitoring Chart allows the prisoner to
grade the severity of their withdrawal symptoms on a level of nought to
three. The HCA said that the form relied on what the woman told her. The
HCA pointed out that the woman graded her nausea/vomiting as three, but
there was no evidence that she had been sick at any point.
(cid:127) The third document was the Benzodiazepine Withdrawal Scale which
allows the woman to grade the severity of their symptoms on a scale of
nought to four. The HCA noted that the woman scored herself a total
score of 62. However the healthcare assistant did not think that this
accurately reflected her appearance and the HCA would have expected
someone with that score to look worse than she did.
(cid:127) Finally the Drug Intervention Record provides an overview of the woman’s
drug history. The woman said that, as she was of no fixed abode, she
would need help with accommodation when she was released. She
explained that she had been a drug user since the age of 14 and spent up
to £250 a week on drugs.
41. Although the HCA thought the woman was coping better than she claimed,
she suffered some withdrawal symptoms including cramps. The HCA asked a
second HCA to request a prescription of Quinine to alleviate her leg cramps.
A prison doctor wrote the prescription although the woman died before she
received the medication.
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42. The woman’s blood pressure was taken again at 4.12pm and it was 109/68
with a pulse of 67. My investigator was told that there was nothing in these
readings that concerned the HCA. The healthcare assistant remembered that
the woman was sitting up in bed during this examination and did not seem
particularly unwell. She did not ask the HCA about extra methadone. The
HCA said that she did not stand out as being particularly unwell compared to
the other women in Styal. She had no concerns about her physical or mental
well-being. She did not mention self-harm or suicide and gave the HCA no
impression that she would consider either.
43. The woman’s dinner was taken to her cell by the wing officer at 5.15pm as
she was not allowed out of her room. The officer asked her if she was going
to tidy her cell and, although they did not have a lengthy conversation, he said
that she gave no indication that she was distressed. He remembered that she
looked tired but said this was not unusual among women in the FNC.
44. Another officer went to make a random check of the woman’s room at
6.30pm. When she looked into room 5 she saw her sitting in the space
between the cell door and her bathroom door. She had a ligature around her
neck made from her identity card lanyard which was tied to the bathroom door
handle. A belt was also attached to the handle. The officer called for help
and another officer left his post in the downstairs office and went to her
assistance. She shouted to him that it was a code blue and he issued an alert
over the radio. (A code blue alert is a medical emergency relating to
breathing.)
45. The officer arrived at the room. They cut the ligature and laid the woman on
the floor. Neither officer could find a pulse or a heartbeat and so they began
cardio pulmonary resuscitation (CPR). The officer ran to get a protective face
mask. As the second officer started CPR liquid came up into his mouth. He
stopped CPR and rolled the woman over to help remove the vomit coming
from her mouth. He then restarted CPR. An SO arrived and a Principal
Officer followed shortly afterwards.
46. A nurse arrived first from the healthcare centre, which is located behind the
FNC. The second HCA followed bringing the mask and oxygen. A senior
nurse was also on her way when she heard a shout for a defibrillator. She
turned back, collected it and went to room 5 with a prison doctor who also
rushed over. The nurse noticed that the woman had no pulse and took over
CPR. The defibrillator was attached but instructed staff not to shock her.
(The defibrillator has an audio device which instructs staff on the procedures
to be followed.) Neither the nurse nor the senior nurse could find any sign of
life. The prison doctor pronounced that the woman was dead at 6.35pm.
Following the woman’s death
47. An ambulance was called by the OSG at 6.33pm and the paramedics arrived
at 6.45pm. They left the cell shortly afterwards as the woman had already
been pronounced dead. They went downstairs to talk to the nurses who had
taken part in the resuscitation attempt. The care team had been informed and
14
were immediately available to offer support to staff involved in the
resuscitation attempt. The nurse explained that additional healthcare staff
came from Waite Wing which meant that the nurses involved were able to
take a break for a few minutes.
48. The prison telephoned the Independent Monitoring Board (IMB) at 7.22pm.
Two board members arrived at 7.50pm and 8.20pm. They went to the
Command Suite to observe the crisis management but did not visit the First
Night Centre. A governor was appointed Family Liaison Officer (FLO) at
8.00pm. The police arrived at 10.15pm and visited the woman’s room. The
police took witness statements from those involved, and left at approximately
3.30am. The prison staff left nine hours after the woman died, as they
volunteered to stay in the prison until they completed their police statements.
Liaison with the woman’s family
49. The prison had difficulty in contacting the woman’s next of kin due to the
incomplete details she provided when she arrived at Styal. She had provided
a mobile telephone number for her boyfriend, but no address as he was of no
fixed address. The Deputy Governor telephoned his number at 8.30pm and
told him that the woman had died. The prison was aware that the woman had
a daughter and was keen to speak to her carer as soon as possible. The
police agreed to go to her address and broke the news to her partner’s
mother, who was the primary carer for her daughter. The news was not
broken until the early hours of 9 January.
50. The police also identified the telephone number for the woman’s mother and
the governor was able to contact her. The deputy governor (the governing
Governor was on leave) and the prison FLO visited the woman’s mother later
that day. Her mother raised concerns about her daughter having a belt and
ID lanyard in her possession. They were offered financial support for the
funeral and the Governing Governor attended the woman’s cremation.
51. The prison also telephoned all the other families who had previously lost
family members at Styal and were still waiting for an inquest. They were told
of the woman’s death so that they did not hear about if from other sources.
Care for staff and prisoners
52. A Principal Officer went over to the residential unit, Fox House, after the
woman died to tell the FNC orderlies and Listeners so that they could be
prepared to support the other women. (A Listener is a prisoner trained by the
Samaritans to provide emotional support to other prisoners.) One of the FNC
orderlies explained to my investigator that she was also offered support from
the prison chaplain. The prisoner who came into the prison with the woman
did not recall being offered any formal support, although she said that a staff
member she worked with had helped her.
53. A healthcare debrief was undertaken at 7.20pm led by the then Head of
Healthcare. A prison debrief was undertaken at 10.25pm which was chaired
15
by Deputy Governor. Healthcare staff were invited but they had already gone
home when the invitation was issued. However, healthcare staff held they
own debrief a few weeks later. The prison counsellor was available for all
staff, and my investigator was told that several staff found this helpful.
54. The officer who attempted CPR went to hospital at approximately 7.30pm for
a health check because of the vomit that had gone into his mouth. A member
of the care team went with him. The officer told the investigator that he had to
organise subsequent health tests himself as the prison did not have any
procedures for such an event.
55. The prison FLO issued the Governor’s Notices to Staff and Prisoners at
9.30pm informing them of the woman’s death. The notice to staff was put on
the gate and they could see it as they came into the prison.
16
ISSUES
Loss of association
56. The woman was suspected of taking drugs in the toilets. Staff could have
chosen to deal with the matter through the adjudication system or the IEP.
57. The first option would have meant that staff placed her on report and
requested an adjudication board to rule on the offence and decide on the
punishment. A punishment of cellular confinement could be applied at an
adjudication hearing after an examination of all the facts by a Governor.
When such a punishment is imposed, sanctions to protect the safety of a
prisoner are put in place, including regular checks, and a doctor assesses
whether the person is capable of coping with such a punishment.
58. However, staff believed that there was an immediate threat of the passing and
sharing of drugs. The adjudication board would not, and could not (due to
certain procedures that need to be adhered to) sit immediately. Consequently
staff decided not to use the adjudication system to deal with the alleged
behaviour.
59. The second option was to use the IEP system. At the time of the woman’s
death Styal had a local IEP policy, designed in accordance with the National
Framework and PSO 4000 and Prison Service Standard 25. The operation of
the system is detailed below:
“Each prisoner, regardless of regime will start the day with a notional
score of 9 points. Prisoners can earn a maximum of 3 additional points
for each credit issued. A score of 12 or over on a daily basis is
indicative of enhanced status. Alternatively 3 warning slips would also
trigger a review from enhanced to standard, or standard to basic.
“When anyone issues either a credit slip or a warning slip they must
place it in the appropriate IEP box positioned around the establishment
… The credit/warning slips will be collected by the collator at 12.00 hrs
every day. Issued slips will be recorded on IEP cards.
“Prisoners start each day with 9 points. Warnings on each of the areas
of behaviour result in loss of points, i.e. 1 per area or six points or less
will result in privileges not being earned on that day. Three warning
sheets will result in a regime review and three credit slips will also
result in a regime review.
“Generally where a person scores 6 points or less they will not be able
to earn association or TV. They will have to remain in their room for
the particular evening. In non cellular accommodation the same will
apply, however control cannot be policed in the same way.”
60. The intention was to issue the woman with an IEP slip with three ticks on it in
order as punishment for the suspicion that she had brought drugs into the
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prison. This was never actually completed. Had it been completed, the
normal process was for the IEP clerk to collect the slip and pass it to the duty
governor the next day in order for any action to be determined. The governor
in charge of the IEP policy explained how the policy was not fulfilled:
“At the time … there wasn’t duty governor approval for the IEP system. It
should have been processed by the IEP clerk the following day and
whether the manager concerned would have activated that loss of
association would have been down to that manager.”
61. However, not only was the procedure not followed, the SO also decided to
impose 24 hours immediate loss of association. The governor in charge of
the IEP policy also explained how the removal of association on should have
been managed:
“If a manager or member of staff are concerned that this person has
secreted drugs, there’s a likelihood of them distributing or trading drugs
on the First Night Centre, the decision then to remove them from normal
association regime should have been the duty governor … ”
62. My investigator found some uncertainty over the application of the IEP policy,
which was reflected in the way it was applied to the woman. The
Ombudsman has commented on the use of IEP warning slips in previous
reports on deaths at Styal and am concerned that this confusion still appears
to be present. The woman’s family also noted their concerns when
responding to the draft report. I am told that the IEP policy is currently being
reviewed, and I encourage the Governor to ensure that the new policy is well
understood by all members of staff.
The Governor should ensure sufficient training is carried out to enable
all relevant members of staff to adequately understand the IEP policy.
63. I am also concerned by the practice of confining someone who is withdrawing
from drugs to their room for 24 hours. I know that this matter was of
significant concern to the woman’s family as well, as they mentioned it again
when responding to the draft report. The loss of association can be a severe
punishment for women who are detoxifying. However, I also understand the
importance of making every effort to prevent drugs being smuggled into
prison. There is also a need to protect other women from being passed
drugs. In the woman’s case, as she was allowed out of her cell for over an
hour the following morning and was not stopped from spending time with the
other prisoners, the loss of association does not seem to fulfil the intended
purpose. The Substance Misuse Development Manager was also concerned:
“… it is not advisable to locate a woman who is withdrawing in isolation
as this can precipitate their anxiety and stress in regards to
withdrawing from substances and personal issues”.
64. I believe that the prison should think very carefully before imposing
punishments in this manner. I appreciate that managers will want to empower
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wing staff to make decisions about the women in their care. However I concur
with the governor in charge of the IEP policy’s view, that a decision to
withdraw association like this, should be taken by a governor.
The Governor should ensure that decisions about loss of association for
women suffering drug withdrawal are taken by the duty governor.
Clinical issues
65. The clinical reviewer’s overall opinion was:
“It is unarguable that the woman received a level and standard of care
at HMP Styal which would be considered to be equivalent to the
standard of care which she would have received had she consulted a
relevant healthcare professional in the community.”
66. However, the clinical reviewer made a number of recommendations that I
would encourage the Governor and Head of Healthcare to seriously consider.
Detoxification and drug support
67. The woman’s family were concerned that she struggled to cope with
withdrawing from drugs and wanted to know about the management of
detoxification. She was a poly-drug user and was withdrawing from opiates
when she arrived at Styal. The clinical reviewer stated:
“The woman’s history of substance misuse was correctly identified by
the healthcare staff at HMP Styal. The nature and extent of the
substance misuse was also identified.”
68. The woman was prescribed methadone to manage her withdrawal. In
accordance with the prescription, she was given 10mls of methadone on the
first evening and another 10mls the following morning. She made it clear to
several members of staff that she did not feel that 10mls was sufficient to
alleviate her symptoms. She complained that she felt unwell when she woke,
again when she met the CARATs worker and also when she spoke to an
officer at lunchtime. This third complaint prompted the officer to raise the
issue with the HCA, who merely reported that she would get another 10mls
that evening.
69. My investigator spoke to the Substance Misuse Development Manager about
the potential flexibility of a methadone prescription. She explained that at the
end of five days prescription for methadone there is an opportunity for the
dosage to be increased if necessary. However, there is also flexibility during
the first five days.
70. She said that if a woman is shown to be clinically withdrawing and is not
stabilised on the standard methadone prescription, then a supplementary
dosage of 10mls methadone can be added. The additional dosage can be
administered six hours after the previous dose as long as it does not exceed
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30mls in the first 24 hours in custody. The standard methadone stabilisation
prescription currently includes an ‘as required’ 10 ml dose of methadone that
can be given during the first night to deal with any withdrawal symptoms. The
woman’s family, when responding to the draft report, felt that all staff
concerned with drug withdrawal should have been aware of the flexibility of
the methadone prescription.
71. There was scope for the woman to be given an extra 10mls when she woke at
approximately 5.30am and again at about 3.00pm in the afternoon. This does
not appear to have been considered by anyone. My investigator was told by
the Substance Misuse Development Manager that she was not aware of
women being prescribed the extra 10mls, although staff should have been
aware of the option. She explained that some women exaggerate their
distress and ask for extra medication whether it is needed or not. The desire
to avoid being misled appears to have resulted in staff failing to consider the
option of an extra dose as often as it might be appropriate. It should also be
noted that the staff who saw the woman did not describe her as acutely
unwell; in comparison to other women they see at Styal.
72. It appears that the woman gave no impression that she would consider
harming herself. She was serving a short sentence and agreed to work with
CARATs staff throughout. Her only apparent concern concerned withdrawal
from drugs. It is not possible, or appropriate, to say that an extra dosage of
methadone would have prevented her taking her life. However, it is a
possible that an extra dose of methadone might have alleviated her distress.
Unfortunately this is speculation. Having conducted interviews with the other
staff who manage prisoners on methadone prescriptions, there does appear
to be some discrepancy between what they think is allowed and what the
Substance Misuse Development Manager explained:
The Head of Healthcare should ensure that staff who care for prisoners
with methadone prescriptions are aware that additional doses can be
administered if necessary.
73. One response from the woman’s family questioned why she did not receive
Quinnine prior to her death. The investigator raised this with the clinical
reviewer who said:
“My view is that prescriber really needs to indicate the timescale within
the medication should dispensed and administered. If the question is
that, should [the woman] have been given the medication at an earlier
stage then I think one would say that yes as the general rule would
need to be that medications prescribed to alleviate symptoms should
be given as soon as possible.”
74. However, the clinical reviewer also pointed out that he had not found strong
evidence to support the effectiveness of Quinnine to control withdrawal
related symptoms. Given this, he stated:
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“Now if the question is whether [the woman] experienced unnecessary
discomfort due to any delay in the administration of the
medication, then I think that given that the medication is of
questionable efficacy then one would answer in the negative.”
Resuscitation
75. Healthcare staff began resuscitation immediately upon arriving at the
woman’s cell. The officer began CPR without a mask, for which he deserves
credit. The prison doctor attended quickly and pronounced the woman dead
within five minutes of her being found. The clinical reviewer wrote regarding
the length of CPR:
“ … no particular significance can or should be attached to the duration
of the resuscitation as the evidence suggests that the woman’s life
could not have been saved. “
76. Whilst conducting CPR some vomit went into the officer’s mouth and after the
resuscitation attempt he left the prison to have his teeth cleaned. He also
needed to have various tests undertaken due to the risks from the vomit. The
officer told my investigator that he had to arrange the tests himself:
“my medical requirements for checking for tests and whatever else,
because obviously we’re not allowed to know the medical history so
you have to assume until cleared. That’s kind of fell by the wayside,
that didn’t really happen. So I had to push for my own tests and go on
justify them to my own doctor as well who asked why the prison wasn’t
doing them and where was our protocol for it.”
77. He later told my investigator:
“But since I’ve come back I’ve spoke to some POA members, I’ve
spoke to, ended up with the prison FLO who spoke to the governing
governor. There’s a system in place now for issuing the masks so that
everybody gets them and trained to use them properly. There is going
to be a principal officer who’s a liaison, an instant liaison officer for the
staff; you know, have you got all, is there anything you need, what do
you need for tests, those kind of things.”
78. The Deputy Governor also spoke to my investigator about this issue. She
explained that first aid staff are being trained to use masks which are being
issued immediately. She explained that the use of masks will be included in
the national heart start training for new officers.
79. I am encouraged to hear that the prison is treating the matter seriously and
make no recommendation due to the work that has already begun. However,
I encourage the Governor to ensure that the work is completed and
procedures are in place should such a situation occur again.
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80. One response from the woman’s family praised the officer’s conduct in
attempting to resuscitate her, while another expressed scepticism that such
an event occurred. All of the evidence reviewed and heard by the investigator
corroborates the account provided by the officer and the investigator has no
concerns regarding the veracity of his account.
Liaison with the woman’s family
81. The prison attempted to contact the woman’s family as soon as possible after
her death. Her partner was called by telephone as she had not provided an
address for him. The PSO relating to deaths in custody strongly advises that
the news is broken in person if at all possible. I understand that the woman’s
partner was of no fixed abode which made it difficult to meet him in person.
82. The carer of the woman’s daughter was told by the police in the early hours of
the morning. In these situations it is imperative that the family is told as soon
as possible and I do not criticise the prison for deciding to involve the police.
83. The woman’s family expressed their concern that she was allowed to have a
belt and lanyard in her possession despite her vulnerability whilst withdrawing
from drugs. The investigator was told by the prison that these types of items
are only taken from prisoners deemed to be at risk of harming themselves.
The woman never gave any indication that she would harm herself and I do
not criticise the prison for their actions. There is a balance between safety
and human decency, and in this case there was nothing to suggest that the
decision should have come down on the side of safety.
84. The responses from the woman’s family to the draft report again raised the
issue of her having a belt in her possession. The report explains that such
items are only taken away from prisoners when it is deemed that they are at
high risk of harming themselves. This view was not held by staff that came
into contact with her. PSO 2700 states:
“However, removing personal belongings from a person who is feeling
hopeless and depressed … can increase feelings of distress and
therefore increase the risk of suicide, self-harm or a higher risk method
of self-harm. Where possible, prisoners at risk should be allowed to
retain their belongings unless it is clearly unsafe to do so.”
85. I understand that the prison contributed to the funeral costs and attended the
service. I am also pleased to record that the woman’s property was returned
to her mother following the funeral.
Care for staff and prisoners
86. The prison took the unusual step of telling other families who had lost loved
ones at Styal of the woman’s death. It was explained to my investigator that
this was done to prevent them finding out through the media and potentially
causing them more distress. I think this is a good example of the prison
continuing to think of the needs of all the families involved.
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87. I was interested to hear that the prison employs a full-time counsellor for the
service of staff and their families. Several members of staff expressed to my
investigator their appreciation of the support the counsellor offered them. I
am pleased to highlight this area of good practice.
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RECOMMENDATIONS
1. The Governor should ensure sufficient training is carried out to enable all
relevant members of staff to adequately understand the IEP policy.
The National Offender Management Service accepted this recommendation
and said:
“The IEP Scheme has been the subject of a comprehensive review and the
recommendations of the review have been accepted by the Governor. The
policy will be amended and a comprehensive training awareness raising to
improve understanding and compliance with policy.”
2. The Governor should ensure that decisions about loss of association for
women suffering drug withdrawal are taken by the duty governor.
The National Offender Management Service accepted this recommendation
and said:
“This is now embedded in the new IEP policy. All cases of women who may
receive loss of association are scrutinised by the Duty Governor who makes
the final decision.”
3. The Head of Healthcare should ensure that staff who care for prisoners with
methadone prescriptions are aware that additional doses can be administered
if necessary.
The National Offender Management Service accepted this recommendation
and said:
“The Head of Healthcare is initiating an awareness programme for all directly
employed Healthcare staff (and openly) to ensure they are aware of the
additional dose that can be administered.”
GOOD PRACTICE
4. The use of a counsellor for staff welfare is an example of good practice.
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