Individual at Cardiff

Investigation into the circumstances surrounding the
death of a man at HMP Cardiff
In July 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
This is the report of an investigation into the circumstances surrounding the death of
a man who died aged 62 years. He had spent 25 hours in the custody of HMP
Cardiff, where he was on remand for the attempted murder of a close family
member. He was found by the officer who unlocked his cell after lunch.
I would like to echo the condolences expressed on my behalf by the senior family
liaison officer to the man’s family. Although the investigation team did not meet the
family during the course of the investigation, I am grateful to the man’s son for his
valuable contribution I hope that my report provides some explanation into the
circumstances of his father’s death. I apologise for the delay producing the report
and any anxiety it might have caused.
The investigation was led by an investigator from my officer, assisted by a colleague.
An independent review into the man’s medical care was undertaken by a clinical
reviewer and a colleague from the Healthcare Inspectorate Wales. I am grateful for
their clinical review that is the first annex to the report.
I thank the then Governor of HMP Cardiff for the support that she gave the
investigation. I am also grateful to the prison liaison officer for the high standard of
liaison he provided the investigation team.
The man assured four individual members of staff during his short time at Cardiff that
he had no thoughts of suicide or self harm. A physically ill man, he had been treated
for depression for a number of years. The violent nature of his offence and his close
relationship with the victim increased his risk of harm himself. Nevertheless, staff
who spoke with him were persuaded that he had no thoughts of suicide. I examine
the reasonableness of this assessment in this report and I also consider whether
family liaison was carried out appropriately.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman September 2010
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CONTENTS
Summary
The Investigation Process
HMP Cardiff
Key Events
Issues
Conclusion
Recommendations
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SUMMARY
The man was remanded to HMP Cardiff on 22 July 2009, following his arrest two
days earlier for attempted murder of his former partner. This was his first time in
prison. On arrival at the prison he was interviewed by a senior officer and a mental
health nurse. Neither had any concerns regarding the risk of harm he posed to
himself. Due to the large amount of prescription medication he had brought into
prison with him, he was then assessed by the prison doctor. It is unclear whether he
was given the prescribed dose of these medications upon arrival and I therefore
endorse the clinical reviewer’s recommendation that staff ensure this is clearly
recorded in future. The doctor did not assess him as at risk of harming himself
either.
Having been interviewed by another officer in reception, the man was placed in the
first night centre in a shared cell that evening. The following morning his cellmate
went to court. The man was interviewed by a chaplain on the wing around 9.30am
as part of the induction process. He also had further routine induction assessments
with a drug worker and an officer working on the wing. He collected his lunch and
was then locked back in his cell. When officers unlocked his cell after lunch, they
discovered him hanging from the bunk bed. Attempts to resuscitate him were
unsuccessful, but were carried out quickly and proficiently. I make no
recommendations in this regard.
The local suicide prevention policy highlighted that prisoners who had never been in
prison before and were facing serious charges were at raised risk of suicide. Both of
these circumstances applied to the man. However, a number of staff carried out
thorough assessments of him, all coming to the same conclusion that he was not at
risk of suicide. I have considered whether it was appropriate not to make him
subject to suicide prevention measures and have found the decision reasonable.
However, not all staff were aware of the seriousness of the charge he was facing
and I therefore make a recommendation about information sharing.
Following the man’s death, his son was requested by the police liaison officer to
identify his father’s body in his prison cell. Understandably this has caused his son
much distress and I have therefore referred the matter on to the Chief Constable of
South Wales Police. I also endorse the second of the clinical reviewer’s
recommendations that details of a prisoner’s death are noted in their medical record.
Lastly, my investigators had difficulty obtaining statements from staff involved in the
care of the man. I therefore recommend that the Governor ensures such statements
are taken quickly in future.
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THE INVESTIGATION PROCESS
1. I appointed a senior investigator to lead the investigation into the man’s death.
She was assisted by another senior investigator. On 27 July 2009, an
Assistant Ombudsman accompanied the second senior investigator to open
the investigation on the first senior investigator’s behalf.
2. During the opening visit, the investigation team met the then Governor, the
Chair of the Prison Officers’ Association and the Chair of the Independent
Monitoring Board (IMB). The liaison officer for the investigation gave the team
copies of the man’s records and showed them around the prison. Notices
were posted around the prison inviting staff and prisoners to contact the
investigator with any matters of relevance to the investigation. There was no
response to these notices.
3. My senior family liaison officer spoke to the man’s son at the beginning of the
investigation. At the time, the family were too upset to meet the investigation
team but expressed several concerns that they wanted the investigation team
to look at. I am grateful for their contribution to my investigation and I trust
that the matters they raise have been effectively dealt with in the investigation
report.
4. I am grateful to the Healthcare Inspectorate Wales for the appointing of a
clinical reviewer to consider the medical care the man received during his
short time at Cardiff. A clinical reviewer was originally appointed, but another
took on the role after the first clinical reviewer moved organisations during the
course of the investigation. Due to the change in personnel, there was some
delay in receiving the clinical review, which in turn delayed this investigation
report. The clinical review is the first annex to the investigation report.
5. After a review of the paperwork, the investigation team went to Cardiff at the
beginning of September to carry out two days of interviews with staff and one
prisoner. They fed back their preliminary findings to the Governor. The
investigation team returned to Cardiff at the beginning of October to conduct
some follow-up interviews with staff involved in the response efforts. The
team also observed the reception process during this visit. Three members of
staff from Reliance (the company who is contracted to escort prisoners
between police stations, court and the prison) came to the prison to be
interviewed on 8 October. Again, the investigation team met the Governor to
discuss their findings and the investigator confirmed their discussion in
writing.
6. The investigator wrote to the prisoner who shared a cell with the man on the
morning of his death. The prisoner was released later that day and
unfortunately did not respond to her request for information.
7. My investigator also wrote to the Chief Constable of South Wales Police in
September about the request to the man’s son to identify his father’s body.
This matter is outside the Ombudsman’s terms of reference. I am grateful to
the Chief Constable for passing the matter for the attention of an Inspector at
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the Professional Standards Department of South Wales Police, who I was
assured would look into the matters raised.
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HMP CARDIFF
8. HMP Cardiff, situated near the town centre, is a local and a training prison. It
can hold up to 784 adult male prisoners. The prison has six residential units,
one of which is used exclusively for life sentenced prisoners, and one for those
going through detoxification. A new healthcare centre was opened in May
2008 that provides 24 hour nursing and medical cover and beds for up to 22 in-
patients.
9. In January 2008, Cardiff was inspected by HM Chief Inspector of Prisons. The
report of that inspection commented as follows:
“Cardiff was essentially a safe prison, where prisoners were much more
likely to report feeling safe than at other local prisons … In general,
support for newly-arrived prisoners was good.”
10. The inspection report also commented that reception procedures were well
organised and efficient. The Inspectorate found that suicide and self harm
arrangements were centrally managed by an experienced safer custody team
with well established policies. They noted that relationships between staff at
the prison and the escort contractor (Reliance) were good, with prompt arrival
of the vehicles and the efficient handover of custody.
11. An Independent Monitoring Board (IMB) is appointed to each prison by the
Secretary of State for Justice. Its members are wholly independent of the
National Offender Management Service (NOMS) and the prison’s
management team. The IMB of every prison is required to produce an annual
report to the Secretary of State, highlighting good practice and areas of
concern.
12. In their report on Cardiff prison for the period 1 September 2007 to 31 August
2008, the IMB noted that the safer custody team at Cardiff “… is very highly
motivated and well respected”. They also found that most suicide prevention
monitoring was initiated in reception, induction and the detoxification unit.
13. The National Offender Management Service (NOMS) is responsible for the
management of prisons in England and Wales. Every three months it
publishes an assessment of an individual prison’s performance against 34
measures. Prisons can gain a rating of between one (serious concerns) and
four (exceptional performance). Cardiff has consistently scored 3s (good
performance) for the last four quarters.
14. The man’s death was the second of four self-inflicted deaths at Cardiff in
2009. There has been one in 2010 at the time of issuing this draft report. All
the deaths were investigated independently by the Ombudsman’s office, and
the lessons were shared between the investigation teams. His death seems
to have little in common with these other deaths.
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KEY EVENTS
Police custody
15. The man went to a police station on 20 July to confess to the attempted
murder of a family member. While in police custody, he was seen by several
members of staff, including a Forensic Medical Examiner (FME). He told the
FME that he suffered from a history of depression and that he had harmed
himself a number of years ago by cutting his wrists. A note was made of this
in the police medical record.
16. The FME prescribed 50 milligrams (mg) diclofenac (an anti-inflammatory) for
the man’s arthritis and 75 mg dosulepin (an anti-depressant). There is also a
note of his previous heart surgery 12 years ago in connection with his chronic
obstructive pulmonary disease (COPD). COPD is a lung disease which
results in sufferers experiencing shortness of breath. The following day he
was again prescribed diclofenac and dosulepin.
Wednesday 22 July
17. The man was taken from police custody to a magistrates’ court. Prisoner
Custody Officer (PCO) A was responsible for processing the paperwork
accompanying those in custody appearing at court that day. He is employed
by a private company, Reliance. The PCO marked on the man’s prisoner
escort record (PER) that he was received into Reliance custody at 10.07am.
(The PER is a form that accompanies each prisoner between court and
prison. It provides information about the prisoner’s needs and the risk he
poses to others.) The first five sections of the PER had already been
completed by the police with the man’s personal details and any risk they
assessed he presented to himself or others. The PCO did not meet him as
was the usual procedure, since he was in an office as the desk officer that
day. He was passed information by the court cells officers and recorded that
information on the prisoner’s files.
18. The man had a large quantity of prescription medication with him and he was
therefore taken to an interview room so he could be easily observed rather
than held in a cell. PCO A said neither he, nor any of the other officers, had
any concerns that the man presented a risk of harm to himself. There was no
information on the PER to indicate a risk of self harm. The PCO could not
recall receiving the information from the police detailing that the man had self-
harmed years ago. He said that if he had received this information he would
have noted it down and informed the senior custody officer.
19. PCO A said he was unsure whether he knew the offence the man had been
charged with, but that custody staff are not routinely informed. Their
assessment does not differ depending on the seriousness of the charge they
are facing and generally it is based on how the prisoner presents and the
information they give themselves.
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20. Due to the seriousness of the alleged offence and the likely length of
sentence, the man’s case was committed to crown court and adjourned until
31 July. He then travelled in an escort van (a large van with small cells
holding around six prisoners) to HMP Cardiff. PCO A said that alternative
arrangements can be made for a prisoner to travel in alternative transport
when there are medical reasons. However, this had not been deemed
necessary by the Reliance control base responsible for managing the process
and he had not requested special transport either.
21. PCO B highlighted ‘medical’ and ‘violence’ as issues on the PER. The man
was not identified as at risk of suicide or self-harm on the form, although
reference was made to something “attached” to the PER which had “further
information about risk”. During interview, he thought that the attached sheet
in question referred to the medication record. He said that, given the short
time that the man was likely to be in the escort’s custody, an estimated 25
minutes, his main concern was to ensure that he had taken all his required
medication. He assured himself that this was the case by looking at the
detained person’s medical record.
22. Working with PCO B that day, PCO C was in the back of the escort van when
court staff brought the man to him. He recalled that he “seemed perfectly
alright”. He said that if either of the prisoner custody officers working on the
escort van were concerned about escorting him, they would have to contact
the Reliance control base so that alternative arrangements could be made.
23. PCO C located the man in cell five of the van and collected his paperwork and
property from PCO B, who proceeded to drive the van to Cardiff. PCO C
explained that the escort van had cameras installed in each cell and a screen
above his head. The screen flicked between the cameras every ten seconds
so that he would be aware of anything “going wrong” in any of the cells within
less than a minute. He remembered nothing of note from that journey, which
he recorded as taking less than 20 minutes.
24. At 12.20pm the man arrived at the reception area at Cardiff. PCO C
remembered escorting him from the van. The prison custody officer recalled
specifically that he was joking because both men were of a similar age. He
described him as being in “good spirits” when he arrived at the prison. The
PCO told my investigation team that he did not consider him at risk of suicide
or self harm throughout their brief contact.
25. This was the man’s first time in prison. The investigation team interviewed
Senior Officer (SO) A, who was working in reception the day the man arrived.
The SO said the man would have waited in a holding cell with other prisoners
until he could be seen. He said between one and ten prisoners usually arrive
over the lunchtime period. On that day, 11 prisoners arrived at Cardiff.
26. The man was then called to the front desk where he was given tobacco,
telephone credit and his private cash counted and secured. SO A had access
to the PER which noted the risk of violence and medication issues. When
asked about the reference to attached sheets on the PER, he said that he
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thought it referred to the record of events, (the second sheet of a PER), where
there is no information noted about risk. When shown the police medical
record during his interview, he said he had not seen it. (The senior officer
said the document would not have altered his assessment of the man’s risk of
self-harm, because the reference was historical.)
27. SO A said he was unaware of the nature of the man’s offence or his previous
history of self harm. When asked whether he considered him at risk of
harming himself, he told my investigators that “there was nothing untoward”
during their conversation that made him think he was at risk of self harm. The
senior officer was unaware that this was his first time in prison since this
information was not immediately apparent from the computer system.
However, he told my investigators that officers always ask a prisoner if it is
their first time in prison. The SO concluded that the man must have told him
that it was not his first time. The senior officer generated a prisoner number
for him, who then had his property logged and his photograph taken by
reception staff.
28. A Registered Mental Health Nurse (RMN) was assigned to work in the
reception area that day, completing the first reception healthscreen. (A first
reception healthscreen is an assessment of the immediate mental and
physical health needs of a prisoner.) She has worked at Cardiff for five years
and estimated that she worked on reception about once a week.
29. The RMN told my investigators that she was aware of the seriousness of the
offence against a family member for which the man was remanded. Officers
in reception had told her the details of the offence. The nurse gave the
following assessment of him during the interview for this investigation,
“My general impression of him was that he was appropriate taking into
account the nature of his offence, he wasn’t over emotional. He wasn’t
withdrawn, he wasn’t negative with what he was saying. He was
talking about the future. He did show remorse but it was appropriate
considering what he had done, he said he had flipped.”
30. The man arrived at the prison with a bag of medication, each with a
computerised record of his name and prescription attached to the bottle. He
explained his medical conditions to the nurse who listed all of his medication.
He had chronic obstructive pulmonary disease (COPD) and coronary heart
disease (CHD), both of which required medication. He also needed to be
nebulised twice a day for his breathing and chest pain to be kept under
control. (A nebuliser is a device used to administer medication to people in
the form of a mist inhaled into the lungs. It is commonly used in acute cases
of COPD.) He took medication for gout, arthritis and tablets to prevent
irritation in his stomach.
31. The man told the nurse that he had been taking dosulepin, an antidepressant,
for five years. He explained that his poor physical condition made him feel
low in mood and that the anti-depressants helped him to cope. He said that
his doctor had gradually decreased the dosage, as his coping skills improved.
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Both the RMN and prison doctor told the investigation that it was unusual for
dosulepin to be prescribed by doctors any more because there is a high risk
of overdose associated with it. The RMN said she considered the prescription
of dosulepin as a “positive indication” that the man was not at risk of
attempting suicide because a doctor would not have prescribed such a drug to
anyone with such a risk.
32. When asked what she considered when assessing the man’s risk of self
harm, she told the investigation team that he was open about his attempted
suicide following a family bereavement. She said “he had no reason” to be
honest with her and was reassured that he was being so open. He was
dismissive about the seriousness of the self harm and she said she believed
his account. He told the nurse that he had no thoughts of harming himself at
the time.
33. During her interview with the investigation team, she recalled that his body
language “corresponded” with what he was saying, for example he made
good eye contact. She acknowledged that the offence that he had committed
was serious but thought that he demonstrated he was coping adequately with
his situation through his body language and the way he interacted with her.
She did not think he was at risk of attempting suicide, and therefore she did
not open an ACCT document. (ACCT stands for Assessment, Care in
Custody and Teamwork and is the Prison Service system used to identify and
support prisoners at risk of suicide or self-harm.)
34. As a mental health trained nurse, she told my investigation team that it was
her view that the man was not suffering from a mental health problem. There
is a section on the first reception healthscreen that examines a prisoner’s
mental health needs. She said that the decreasing dose of antidepressants
was an indication that his depression had stabilised over the previous five
years. She told my investigation team that she did not consider the
circumstances of his sudden violent offence as evidence of mental illness.
She said “I think people get angry that doesn’t necessarily mean they are
mentally ill, it means they get angry.”
35. She made a referral for a mental health assessment. During interview for this
investigation, she explained that the man only needed a mental health
assessment because he was prescribed anti-depressants. Whilst this is the
case, he would also have needed to be referred as he told the nurse about a
previous occasion when he harmed himself 25 years ago. Additionally, on the
healthscreen template there is a note that if the prisoner is charged with
murder or manslaughter, they should be referred for a mental health
assessment. (It is not clear if this should also be the case if the prisoner
charged with attempted murder, as he was.)
36. After the first reception healthscreen, the RMN contacted the doctor on duty in
the prison that evening. The nurse explained to the investigation team that
not all prisoners arriving at Cardiff are examined by a doctor in reception.
Due to the man’s complex medical needs, she thought it was appropriate to
get a second opinion. The doctor was working in an office in the healthcare
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centre when she received the call. She agreed to assess the man and made
her way to reception. During interview for this investigation, the doctor told
my investigator that the nurse sounded unsure about the man’s diagnosis
and, while confident in assessing his mental health needs, she wanted
reassurance about his physical health needs.
37. The doctor joined the RMN and the man in the private healthcare room in
reception. She remembered that he was remorseful when talking about his
offence but otherwise appeared to be coping with his situation. As he
described his medical conditions and related treatment, she was impressed
by his grasp of such a complex set of needs. She told my investigator that he
required nebulising twice a day and this was available on the wing. He said
he often experienced a tight chest, she recommended that he be located on
“the flat”, that is the ground floor to avoid using stairs. She explained that he
would have to collect his medication from the treatment hatch until such a
time he was assessed as able to have it in his possession. (For the first few
days of custody, he would have had to climb one flight of stairs for his
medication, but would have been located on “flat” after induction.)
38. The doctor said she had no concerns about the man’s risk of suicide. She did
not discuss his history of self-harm, because she did not read it on the first
reception healthscreen until after the examination. However, she was
satisfied that the RMN would have made an appropriate assessment,
because of her mental health training.
39. The doctor told my investigators,
“I searched specifically to get a feeling, because of his past history of
depression, about the risk to himself and I asked him first about
depression in general, why he is on an anti depressant? How long he
had been on them and then I asked him how did he feel about being in
prison and would that change his depression? Would it make it worse?
Would he think he would cope? I offered him all the help he can
possibly get or who to talk to if he felt worse and I asked him whether
he felt suicidal, to which he said, doctor I would never do that.”
As the man maintained eye contact and his manner did not change when he
responded to this question, she believed that he was speaking the truth. (She
noted down an account of their conversation as soon as she learned of his
death. She told my investigation team that she was confident that he used
the words “I would never do that”.)
40. Again, the doctor recorded in the man’s medical records that his
antidepressant was a decreasing dose. She told the investigation team that
she “didn’t detect any” signs of depression. She explained that there was
“constant” eye contact during their meeting and “he smiled, we laughed about
the smoking”. The doctor did not assess him as having a mental health
condition.
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41. Having confirmed the man’s prescription medication with his community GP
by telephone, the doctor prescribed him a number of medications that
afternoon including diclofenac and dosulepin. It is unclear whether he was
given the diclofenac medication as prescribed.
42. Officers from the induction unit meet every prisoner in reception before they
are escorted to the first night centre (part of the induction unit) for their first
few days in custody. Officer A, an officer on the induction unit, explained the
aim of the arrangement is to build up a rapport with prisoners, especially
because the first night in prison can often be the hardest to cope with.
43. Officer A met the man in reception when he completed the first part of the Cell
Sharing Risk Assessment (CSRA – used to assess a prisoner’s risk to others
and determine whether it is safe for them to share a cell.) During interview,
he explained to the investigation team that reception staff were responsible for
completing section one of this form. The ‘current offence’ section on the
CSRA was incorrectly filled out as “failure to surrender”, but it was not the
officer’s writing. All other information regarding his current and previous
history of offending was gained from the man himself. The officer was
unaware of the violent nature of the offence with which he had been charged.
44. Officer A also completed the reception screening part of the man’s induction
file. He disclosed that 25 years ago he had cut his wrists but had no current
thoughts of suicide. The officer told him about the Listener scheme (this is a
confidential service whereby prisoners can talk to other prisoners who have
been trained as ‘Listeners’ by the Samaritans). The man was also offered a
telephone call, which he declined. The officer judged that he was not at risk
of harming himself and described him as “jolly” during this exchange. He
cannot remember seeing him after this assessment until the following morning
when he was working on the induction landing.
45. The RMN also filled out the healthcare section of the CSRA while he was in
reception. She wrote: “Locate flat. First time in prison. Fit for normal
location“. The nurse indicated that the man was a low risk and was suitable to
share a cell with another prisoner. When asked during interview what the
alternative to “normal location” was, the nurse explained that prisoners can be
accommodated in safer cells or admitted straight to the healthcare centre. (A
safer cell has fixed plastic furniture, with the aim of reducing ligature points.)
She told my investigators that she had not considered him at risk of suicide or
self harm and so a safer cell was not appropriate. As for admitting him to the
healthcare centre, she considered that, while he had complex medical issues,
he would be able to manage these on a residential wing. Therefore, she did
not recommend that he be admitted to healthcare.
46. While the nurse filled in part of the CSRA, the doctor signed and dated it. She
told my investigation team that she agreed with the nurse’s assessment that
the man should be located on a residential wing. She explained that she was
satisfied that he understood and managed his medication well and she
wanted to promote the same independence that he was used to in the
community. He was located in the first night centre in a shared cell. The
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nurse contacted his community GP because he said he was taking Tramadol
(a painkiller) but he did not have any evidence to support this. During her
telephone conversation with the surgery, she discovered that he was not
prescribed Tramadol, but she was able to confirm the other medication in his
possession.
Thursday 23 July
47. Officer B arrived for his main shift duty at 7.30am on 23 July. He had not
been on duty the previous day. During interview for this investigation, he
remembered that instead of the usual three officers on the induction unit,
there were only two working that morning, himself and Officer A. Officer A
confirmed this. Officer B said they completed a roll count (when staff count
prisoners) and then unlocked the prisoners who were going to court. The
man’s cellmate was due to appear in court that day, so he was escorted to the
reception area at about 7.45am, leaving the man alone in his cell.
48. Officer B described the morning as “nothing out of the ordinary”. Prisoners
were unlocked at about 8.00am to make applications to use the telephone or
for a medical appointment. There is no record that the man made any such
application. He collected his medication from the treatment hatch at about
9.00am. The doctor remembered overhearing nurses arranging the nebuliser
for his use. He then returned to his cell.
49. At 8.38am a worker from the prison’s custody team sent two emails. (The
custody team perform an administrative function, collating prisoners’ records.
They do not meet prisoners during the course of their work.) The first email
alerted prison staff to the offences with which the man had been charged.
The second was sent to safer custody staff advising them of a “self harm
warning in his core records” and also that he suffered from depression.
During the investigation, my team visited the custody team worker in her office
and asked what information would have triggered that response. She said
that she was acting as a result of the note in the police medical record about
his historical self harm.
50. No one visited the man as a result of the worker’s email. During interview,
Safer Custody Manager was asked what action would be taken on the receipt
of such emails. He said usually safer custody staff would aim to see the
prisoner the same day to assess their risk of self harm or suicide but at the
latest they would be seen the next day.
51. A sessional chaplain visited the man at about 9.30am on the wing. A chaplain
usually visits prisoners within 24 hours of their arrival. She spent about ten
minutes at his open cell door, discussing his faith and any needs he might
have. She told my investigation team that she talked to him for a bit longer
than usual because, as a Christian Spiritualist, his faith was uncommon at the
prison and she wanted to explain what was available to him. He asked her to
put him on a list to attend the Sunday Church of Wales service and said he
would consider being visited by a local Christian Spiritualist priest.
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52. The chaplain asked him whether he had any thoughts of harming himself, and
believed him when he said he did not. He mentioned that his offence was one
of domestic violence but he did not go into detail and she did not ask him to.
When she locked him in his cell after the conversation, she noticed no
indication that he was at risk of harming himself. She told the investigation
team that if she had any such concerns, she would have communicated this
to the safer custody team immediately.
53. The investigation team tried to contact the man’s cellmate during the
investigation. He was released from Cardiff after going to court on the
morning of 23 July. The investigator subsequently wrote to him to
communicate the news of the man’s death and ask for any information he
thought would be relevant. The investigator received no response to that
letter.
54. The investigation team spoke to one of the prisoners located on the induction
landing on 22 July. Of the other prisoners who arrived on the same day as
the man, only one prisoner remained at Cardiff. During interview he said that
he had been talking to the man on the morning of 23 July while they were the
only people in a room waiting to see someone. He thought they were waiting
to be assessed by a Counselling, Assessment, Referral, Advice and
Throughcare Service (CARATs) worker. Documents confirm that the man
was seen that morning by a CARATs worker whom explained the services
they could offer him. (CARATs works with prisoners with substance misuse
needs and sees every prisoner as part of the induction process.)
55. The prisoner remembered that the man told him why he was in prison and he
noticed he seemed upset as his bottom lip was “quivering”. He said the man
seemed “quiet, subdued and depressed”. He also remembered talking to
another prisoner who said the man had said to him “don’t worry I won’t be
here for long”. He did not mention suicide or self harm to the prisoner. He
told my investigators that he had not thought the man was at risk of suicide
otherwise he would have informed Officer A or Officer B who he said were
“nice and approachable”. He also said he was not aware of any prisoners on
the landing reacting in a negative manner to the man. He thought it unlikely
that he would have been bullied or threatened since he had been on the
landing such a short time.
56. At about 11.00am that morning, the man undertook a voluntary drug test on
the landing above the induction unit. After the test, at 11.30am, Officer B took
him to a private office to complete the Induction Passport. He explained the
incentives and earned privileges scheme. (This is a system to reward good
behaviour in prisons. There are three levels: basic, standard and enhanced.
Incentives can include access to in-cell television, more private cash or
prisoners being allowed to wear their own clothes.)
57. Officer B also explained the prison’s diversity policy and suicide prevention
policy. He told my investigators that he always outlined procedures for
monitoring suicide or self harm, and asked prisoners to approach staff with
any concerns about themselves or others. The man signed to agree that he
15
understood the policy. The officer said he had no concerns about his risk of
suicide. After the ten minute interview, the man returned to his cell until it was
time to collect his lunch.
58. Lunches are collected from the landing above the induction unit at 11.45am.
Other landings collect their lunch first and F1, where the man was located, is
the last of the four landings to get their meal. The meals are given to
prisoners on a tray at a servery. The prisoners take their lunch back to their
cells where they are locked in to eat. Neither Officer A nor Officer B could
remember which officer locked his cell that lunch time.
59. During the lunch hour, all the prisoners were locked in their cell and only one
officer remained on the landing. On 23 July, Officer A had some errands to
run and he left the induction unit, leaving Officer B to carry out the lunchtime
shift. Officers do not check prisoners during their lunch, unless they are
subject to ACCT or at risk of escape. Officer B did not check the man during
that lunchtime. Cell bell records confirm that he was not called to his cell or
those adjacent to it.
60. Officer A returned to the unit at 1.30pm. The two officers agreed to clear the
lunch trays from each cell, a matter of routine. Officer A did cells one to ten
and Officer B collected trays from cells 11 to 22. Officer B started at cell 22,
collecting the two trays from prisoners in there. Next he moved to cell 21, the
man’s cell.
61. Officer B checked through the observation panel on the cell door. He thought
the man was sitting on the bottom bunk. The officer used his key to unlock
the door. As he did so, he noticed that the man had a plastic bag over his
head. He had tied a leather belt around his neck and attached it to the bunk
above. Officer B shouted to Officer A, who ran to the cell. He saw the man
and then ran the few metres to the end of the landing to press the alarm
button. Officer A told the investigation team that he used the alarm to alert
staff that they needed assistance.
62. In the meantime, Officer B used the anti-ligature knife that he carried with him
(all officers carry an anti ligature knife on their belts) to cut the belt and
remove the bag from the man’s head. Officer A then called a Code Blue over
the radio and checked for a pulse but could not detect it. (Code Blue is the
emergency code used when someone has stopped breathing.) Officer C then
went into the cell and helped Officers A and B move the man to the floor. (A
hard surface is more efficient to perform resuscitation than a soft surface, like
the bed.) Officer B told my investigators that he thought the man had died.
The officer remembered that he was cold to the touch. Officer C then started
cardio-pulmonary resuscitation (CPR) since he was better placed to do so in
the small cell than Officers A and B.
63. Physical Education Officer (PEO) A and PEO B arrived at the cell seconds
later. As they are both first aid instructors, they offered advice to the officers
trying to resuscitate the man. They suggested moving him out of the cell but
PEO A said that this did not happen and they began moving furniture out of
16
the cell instead. Since the cell was becoming crowded, Officers A and B went
to a nearby quiet room where they were supported by the care team.
64. PO A and Officer D then arrived with restart kit (continuing medical equipment
for emergencies) with PO B. (As the Orderly Officer, PO B was in charge of
the prison that day.) Officer D gave Officer C a face shield for protection
during resuscitation. The radio controller called an ambulance. (According to
the communications log, the ambulance was called three minutes after the
initial alarm was raised.)
65. Four members of staff from the healthcare centre arrived with the defibrillator,
one of whom was a Healthcare Senior Officer (HCSO). (A defibrillator is a
device used to measure whether there is any activity in the heart that might be
restarted using an electric shock.) The HCSO is also a qualified nurse. He
had been carrying radio Hotel 3, meaning he was tasked to respond to any
emergencies. The defibrillator was attached to the man and the relevant
checks were carried out. Officer C recalled that the defibrillator, which he was
trained to use, instructed that it should not be used and that resuscitation
efforts should continue. PEOs A and B returned to their department at this
stage.
66. CPR was continued by Officers C and D administering chest compressions,
swapping on each set, while the HCSO inserted an airway and used an
ambubag to pump air into the man. (An ambubag is a self inflating bag used
to administer oxygen.) Two nurses offered to take over CPR every few
minutes but this was declined and they remained outside the cell. They
passed medical equipment to officers as requested.
67. The ambulance arrived at 1.49pm, 15 minutes after the man was initially
found. Officers continued to administer CPR under instruction from the
paramedics until their equipment was set up. The paramedics attached their
own defibrillator and continued to attempt resuscitation until 2.16pm when
they decided that nothing that more could be done for him. They waited for
the doctor to arrive who could pronounce death. Officers C and D said a
prayer over the body, while they waited for the chaplain.
68. The Chair of the IMB was on the induction unit visiting another prisoner. She
remained on the unit to provide support to staff and answer prisoners’
questions. The Governor arrived a few minutes later and evidence was taken
from the man’s cell. He was then blessed by a chaplain, with the Governor
and Officer C present. The doctor arrived and pronounced the man dead at
2.55pm and an officer secured the cell. A debrief was held for staff involved.
Family liaison
69. When a prisoner is taken into custody, they are asked by escort staff for
details of their next of kin. The man gave the name and contact details of his
17 year old son. Upon discovering the age of the named next of kin, PO A,
charged with locating details of the family, decided it was inappropriate to
break the news of his father’s death to someone so young. He tried another
17
telephone number on the records but there was no response. (It was likely to
have been the man’s own telephone number.)
70. PO A asked the police liaison officer to find an alternative contact to break the
news of the man’s death. (A police liaison officer is a trained police officer,
based in the prison.) The police found a mobile telephone number for an
older son. When the PO contacted the man’s older son, he was driving into
Cardiff City Centre. During interview for this investigation, the PO said that he
did not want to explain the reason for his call while the man’s son was driving
and over the telephone. The son offered to come to the prison to speak with
the PO. In the interests of breaking the news of the man’s death as quickly as
possible to avoid his family learning of it from another source, the PO agreed
to meet him about half an hour later at the prison gate.
71. The Governor and the PO met the man’s son at the gate and escorted him to
the Governor’s office, where they broke the news of his father’s death. On his
way out of the Governor’s office, the son passed the command suite, where
the police remained carrying out their duties. A police officer asked him if he
would accompany him to the cell and identify his father’s body. Despite being
unhappy with this irregular arrangement, the PO did not feel able to challenge
the police officer’s request and thought he had no choice but to escort them to
the cell. I am surprised that, in the interests of efficiency, the traumatic and
personal experience of identifying his father’s body had to be carried out in
such an inappropriately public environment. The man’s son was still upset
about this encounter when he spoke to my family liaison officer weeks after
his father’s death.
72. An associate psychologist, based in the safer custody department, was
appointed family liaison officer for the prison on the Monday following the
man’s death. He telephoned the older son that day to explain that the prison
would contribute to the funeral expenses. He also asked whether the family
would like anyone from the prison to be at the funeral. The son confirmed the
date of the funeral but asked that no one from the prison attend.
73. After the funeral, the psychologist arranged with the coroner’s officer for the
man’s property to be released to the family. On 27 August, both he and the
PO met the man’s son with his property at the prison gate. The son
discussed some of his concerns with them, who assured him that my office
would seek to address these concerns as far as possible. I trust that I
adequately explore these matters in the following section, insofar as they are
within my terms of reference.
Prisoner Support
74. Although the man was not at Cardiff for long, prisoners on the induction unit
were offered support from the Chaplain and Listeners. (Listeners are
prisoners trained by Samaritans to provide confidential emotional support to
fellow prisoners in distress.) A memorial service was held for him in the days
after his death.
18
Staff support
75. Following the man’s death, all staff were asked to remain in the prison to give
statements to the police. Officer C asked to be relieved because he was not
ready to give his statement. He was told that he was not allowed to leave the
prison or clean himself, as his clothes had to be tested for evidence. Given
that the man died in a locked cell on his own and third party involvement was
unlikely, I am surprised that the gathering of evidence needed to be so
intrusive. It is not the practice which I usually discover in my investigations.
The Chair of the IMB brought this matter to my attention. I understand that it
was the police liaison officer who asked the officer to remain in the prison. I
referred the matter to the Chief Constable in South Wales, who assured me
that it would be dealt with by the professional standards department.
76. All staff told me that they were able to access care and support services
through the prison. Officer C explained that he was having some difficulty
coming to terms with his phased return to work. I understand that such a time
can be difficult, but was assured through discussions with the Governor, that
the matter was being dealt with appropriate sensitivity.
77. A debrief was held after the man’s death as an opportunity for staff to go
through what happened on 23 July and offer support to each other. Officer C
told the investigation team that he felt unable to attend the debrief because it
was “not right for him at the time”. He also said that he was surprised such a
debrief would be held at the prison, although he acknowledged that it makes
things easier for most staff for operational reasons.
19
ISSUES
Did staff miss any signs that the man was at risk of suicide?
78. During the 25 hours the man was at Cardiff, his risk of attempting suicide was
formally assessed by a nurse, doctor, reception officer and a chaplain. Other
officers and a CARATs worker also met him in his short time in prison. No
one raised concerns about his risk of self harm and, as a result, no ACCT was
opened.
79. The man was on remand for a violent offence, the victim of which was a close
family member. It was his first time in prison and his physical health was
poor. The prison’s suicide prevention guidance for staff describes three
categories of prisoner who are at greater risk of suicide. Firstly, a prisoner
who has poor coping abilities, secondly a prisoner with or facing a long
sentence and thirdly prisoners with mental health issues. He came into the
second category of prisoner as he had been charged with a very serious
offence. Within this category the guidance says that violent offenders are at a
particularly high risk, especially for offences within the family. The risk is
further increased during the period a prisoner is on remand. Both of these
additional risk factors applied to him, who was also being treated for
depression.
80. The guidance notes that the “main motivating factors are guilt, shame,
worthlessness and lack of hope for the future”. According to the guidance,
levels of previous self harm among such offenders are low and suicide
attempts tend to be well planned and more determined than with those with
poor coping abilities. The man’s apparent suicide could be seen as a
determined effort given the use of both a ligature and plastic bag.
81. The same document also gives detailed information regarding verbal and
nonverbal cues which indicate an increased risk of suicide. For example,
poor personal care, withdrawal, food refusal, expression of boredom or of
missing their family and hopelessness. The guidance goes on to list
behavioural cues to an increased suicide risk, such as mood changes or a
prisoner being unable to sleep. The section concludes:
“Suicide is ultimately a matter of choice. We can usually influence that
choice and should always seek to intervene. However, there will
always be some who do not seek or respond to help. Not all suicides
are preventable.”
82. I am pleased to have found a system whereby information given to the prison
is considered and every prisoner arriving in custody with a self harm warning
is visited by a member of the safer custody team. The worker from the prison
custody team emailed on the morning of 23 July to notify staff of the man’s
history of self harm, as recorded on his police custody record. Unfortunately,
the safer custody team did not visit him that morning. The investigation team
made a spot check of all these emails which had been sent in July. They
found that out of 30 alerts, all of the prisoners had been visited at some point
20
by a member of the safer custody team. The vast majority, 25 prisoners, were
seen the same day or the day afterwards. Of those, only one prisoner was
placed on an ACCT as a result of the Safer Custody team’s visit.
83. However, whilst the risk factors described above are concerning, they must be
weighed against the clinical judgement of staff who saw the man during his
brief time in prison. The RMN and the prison doctor were aware that it was
his first time in prison and understood the nature of his offence. However,
whilst taking this into account, his presentation did not give them any concern
that he was at risk of suicide. They remembered what he told them during his
conversations, and also recalled how consistent his body language was with
his assurance that he was not going to harm himself.
84. I understand that the Cardiff safer custody team has introduced a system to
support prisoners who have committed serious violent or sexual offences
against a family member. I am pleased that they continue to recognise the
risk associated with such a prisoner. I am careful not apply the benefit of
hindsight in my investigations. I am satisfied that all those who came into
contact with the man considered his risk of self harm. Some were aware of
the details of his offence and some were not, but he was spoken to at length
about any thoughts of harming himself. It is my view that staff considered his
risk of self harm sufficiently and made an informed decision based on what he
told them and how he presented.
85. The man’s family were concerned that he had been allowed to keep his belt
when in prison. My interviewers questioned PO A about this decision. He
said that, since staff did not consider him to be a risk of suicide or self harm
he was allowed to keep his belt. If staff had thought him to be at risk they
would have taken it away and considered relocation to a safer cell. The PO
pointed out that other items in the cell, such as bed sheets, could have been
used to make a ligature and it was not possible or appropriate to confiscate all
such items from all prisoners. This would only happen when a risk of self
harm or suicide was assessed. This is in line with the requirements set out in
Prison Service Order (PSO 2700) – Suicide and Self Harm Management.
(PSOs set out the rules by which prisons are run.) According to PSO 2700,
staff should consider alternative action before removing personal items from
prisoners who have been assessed as at risk of self harm. Given my opinion
regarding the reasonableness of not opening an ACCT, I believe that staff
allowing him to keep his belt was appropriate.
Information sharing
86. Some members of staff were not aware that this was the man’s first time in
prison or of the nature of his offence. They included the two officers who
worked on the induction wing where he died. Prison Service Order (PSO)
2700 relates to suicide prevention and self-harm management. It says:
“Establishments must make provision for additional risk assessments
and care to keep safe prisoners who have been charged with domestic
violence and/or domestic murder/murder of a family member. Such
21
provision must include ensuring a record is maintained to show what
action has been undertaken.”
87. PSO 2700 also says that all new prisoners are asked whether they have been
in prison before and that all information gathered during reception should be
available to staff commencing the induction process.
88. I conclude that the decision not to make the man subject to ACCT procedures
was reasonable. Their judgement was based on in-depth and frank
conversations about how he felt at the time of his remand. However, in order
to make more informed risk assessments and accurately note changes in
mood, it seems the officers in contact with him should have known about his
offence and that it was his first time in prison.
89. My investigators were told that this information was not shared because it was
recorded on the first reception healthscreen, which formed part of the medical
records. Medical records were considered confidential. Information relating
to a prisoner’s safety needs to be shared. Aside from this, since it was the
man’s first time in prison, he was likely to need a more thorough explanation
of the regime and his rights. I therefore make the following recommendation:
The Governor should consider a system whereby information which is
known to be a risk factor in self harm or suicide is shared fully amongst
all those who come into contact with the prisoner.
90. I am pleased to note that a new system has been introduced at Cardiff,
whereby prisoners who have committed a certain class of violent offence,
especially involving a family member, are monitored by staff in the early days
of custody.
Prescription of medication
91. The man arrived at Cardiff with a number of different types of prescription
medication. Having spoken to his community GP, the prison doctor re-
prescribed these, including the anti-inflammatory diclofenac. However, the
clinical reviewer notes that it is not clear whether he was given this medication
as prescribed. It was not signed for and the nurse was unsure if she had
administered the medication or not when asked during interview.
92. The clinical reviewer goes on to say:
“All healthcare staff should comply with the Nursing & Midwifery
Council (NMC) Standards for medicine management which clearly
states that ‘You must make a clear, accurate and immediate record of
all medicine administered, intentionally withheld or refused by the
patient, ensuring the signature is clear and legible’. The standard goes
on to state that ‘Where medication is not given the reason for not doing
so must be recorded’.”
93. I therefore endorse the clinical reviewer’s recommendation that:
22
The Head of Healthcare should ensure a clear record is kept of any
medicine which has been administered, intentionally withheld or
refused. If the medication is not given, the reason for not doing so must
be recorded.
Emergency response
94. On discovering the man, the emergency code was effectively communicated
and an ambulance promptly requested. Both officers and healthcare staff
responded quickly and professionally to the emergency. Indeed, the clinical
reviewer comments:
“It appears from interview evidence that first responders acted quickly
to attend to the man and undertook CPR appropriately until the
paramedics arrived to take over. We have no recommendation in this
regard.”
I also have no recommendation to make in this regard and am pleased to
observe the prison’s contingency plans working effectively.
Medical record keeping
95. The clinical reviewer notes that:
“The clinical records provided only contain the first reception health
screen and the doctor’s initial medical assessment. There is no
documentation related to the man’s death in the clinical records.
“Healthcare staff should ensure as far as is practicable that a
description of the event of a death and the activity undertaken to
resuscitate the individual is clearly documented in the clinical records
including the time the ambulance arrived and doctor pronounced the
prisoner dead. Records should identify any risks or problems that have
arisen and show the action taken to deal with them as stated in the
NMC Record Keeping: Guidance for Nurses and Midwives (2009).”
96. I therefore endorse the clinical reviewer’s recommendation that:
The Head of Healthcare should ensure detailed medical records are kept
in relation to a prisoner’s death in line with the NMC guidance.
Family liaison
97. The man’s son told my Senior Family Liaison Officer of his distress at having
to identify his father’s body in the cell where he died. In my experience of
investigations this is not usual practice and the Safer Custody Manager
confirmed that he had never known it to happen before. Indeed, he went on
to say he felt very uncomfortable with this happening in the cell. I understand
that it took place at the request of the police liaison officer, located in the
23
prison. Since they are employed by South Wales Police they fall outside of
our remit. My investigator has therefore written to the Chief Constable of
South Wales Police to inform them of our concerns in this respect. I am
unable to comment further and trust that this matter will be effectively
investigated by the police. I will also send a copy of my report to the Chief
Constable.
Staff statements
98. Cardiff has written its own compulsory guidance to staff following a death in
custody. This is in addition to PSO 2710 which relates to deaths in custody.
The Cardiff policy says that “the Orderly Officer will gather all written reports
from staff prior to them going off duty, submitting the reports to the Duty
Governor”. According to the guidance, statements are supposed to be taken
from staff and prisoners including:
(cid:127) Staff who were first on the scene
(cid:127) Other staff attending the incident
(cid:127) Last person to see the prisoner alive
(cid:127) Death in custody staff check lists
(cid:127) Prisoners in adjacent cells
(cid:127) Personal Officer report
99. In the man’s case this would have amounted to over 20 statements. Despite
requests, my investigators did not receive any staff statements until they
visited the prison on 3 September when they were given three. After this they
were given a further four statements during the course of the investigation.
100. The lack of statements caused difficulties for a number of reasons. Perhaps
most importantly, those people who were interviewed were required to
describe their involvement with the man in more detail. This could have led to
unnecessary additional distress to staff who were the first find him and try to
revive him. Officer C expressed his concern that it had been so long before
he had been able to go through what happened on 23 July. It might also have
led to a less accurate account of events being given to my investigation team
as the time passed affected staff’s recollections.
101. I acknowledge that it might be difficult for staff to recount their version of
events so soon after going through something so upsetting. However, there is
a requirement for statements to be made. I hope that systems will be put in
place for staff statements to be written promptly in the future.
The Governor should work with the safer custody manager to ensure
prompt statements are taken following a death in custody, in line with
the requirements of PSO 2710.
24
CONCLUSION
102. At the age of 62 the man was remanded into custody for the attempted
murder of a close family member. Research has shown that this charge,
along with the fact that this was his first time in prison, made him more
susceptible to the risk of suicide or self-harm. He apparently committed
suicide 25 hours later.
103. During his brief time in custody, the man was interviewed by a doctor, mental
health nurse, chaplain and prison officers. No-one thought he was a risk to
himself and an ACCT was not opened. Having spoken to staff, I am satisfied
that their assessments were reasonable and am not critical of the decisions
they made. It seems that he took the first opportunity he had to take his life
and was determined both in his attempt and to ensure staff were not aware of
his intentions to do so.
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RECOMMENDATIONS
All recommendations were accepted. The proposed action is written in italics
following each recommendation.
1. The Governor should consider a system whereby information which is known to
be a risk factor in self harm or suicide is shared fully amongst all those who
come into contact with the prisoner.
Cardiff prison to comply with National Policy for Safer Custody issues. (PSO
2700 Suicide and Self Harm Prevention). This details effective information
sharing protocols.
2. The Head of Healthcare should ensure a clear record is kept of any medicine
which has been administered, intentionally withheld or refused. If the
medication is not given the reason for not doing so must be recorded.
Notice to staff to be issued reminding them that all medication must be
recorded and if omitted or refused this is document.
3. The Head of Healthcare should ensure detailed medical records are kept in
relation to a prisoner’s death in line with the NMC guidance.
The clinical record to be made available to medical staff to enable them to
record clinical entries. Medical staff involved in death in custody to record in
clinical record.
4. The Governor should work with the safer custody manager to ensure prompt
statements are taken following a death in custody, in line with the requirements
of PSO 2710.
Cardiff prison to comply with PSO 2710 ensuring that statements are taken
promptly from identified grades in conjunction with police statements.
26