Individual at Bullingdon

Investigation into the circumstances surrounding the
death of a man at HMP Bullingdon
in January 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
This is the report of an investigation into the death of a man at HMP
Bullingdon. He was found in his cell in the early hours of the morning of 9
January 2009, having made cuts to his neck with a razor blade. At the time of
his death he was in the midst of his trial at Crown Court for the alleged murder
of his wife. He was 49 years old.
I extend my condolences and those of my colleagues to the man’s family. I
hope that my report goes some way to answering any questions they may
have. I must also apologise for the delay in completing this report.
The investigation was carried out on behalf of the Ombudsman by one of his
investigators. A clinical review of the man’s healthcare at Bullingdon was
conducted by a clinical reviewer on behalf of the local Primary Care Trust
(PCT). I am most grateful to the clinical reviewer and his review is annexed to
this report. I would also like to thank all of the staff at Bullingdon for their
cooperation with my investigation. I would particularly like to thank Governor
A for her assistance. This is the sixth apparently self inflicted death to have
taken place at Bullingdon since the Ombudsman started investigating such
deaths in April 2004.
It is evident from my investigation that the man was a quiet man who, for the
most part, kept himself to himself and was respectful to staff. He apparently
committed suicide towards the end of the first week of his trial. When he
arrived at Bullingdon he was placed on an Assessment, Care in Custody and
Teamwork (ACCT) document, being observed constantly due to his attempt to
harm himself at the time of the offence. However, he spent the last six
months of his life on one of the prison’s regular units.
The murder of a close relative or partner is an acknowledged risk factor of
suicide, as is a history of self harm and the additional stress of the trial. On 7
January during his trial staff at the prison were informed that, due to
comments made by the man to his solicitor in court, a Suicide Self Harm
Warning Form had been raised. However, having been assessed on his
return to Bullingdon by a nurse, who concluded that he was not at risk of
harming himself, no further action was taken by the prison. Sadly he was
found in his cell, in the early hours of 9 January, having apparently taken his
own life.
As a consequence of his circumstances, the man was a prisoner at high risk
of harming himself. However, from the nurses assessment of his general
demeanour at the time, I do not believe that his death could have been
reasonably predicted by staff at Bullingdon. I make a number of
recommendations, the most significant being the importance of referring
prisoners who have committed a violent offence to a psychiatrist. Other
recommendations include the completion and referencing of prison records
and a reminder to staff of the actions to be taken during an emergency at
night.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman February 2010
CONTENTS
Summary 4
The Investigation Process 6
HMP Bullingdon 8
Key Findings 10
Issues 18
Conclusion 26
Recommendations 27
SUMMARY
On 2 June 2008, the man who is the subject of this report was remanded into
custody at HMP Bullingdon having been charged with the murder of his wife.
Because he appeared to have harmed himself after the alleged offence, he
had been placed on a constant watch whilst in police custody.
The man was placed by prison staff on an Assessment, Care in Custody and
Teamwork (ACCT) document. (The ACCT document is used to assess,
observe and support prisoners at risk of harming themselves.) He was
assessed by a nurse and it was decided that he should be located in the
prison’s healthcare unit under constant observation.
Whilst in healthcare he continued to speak of harming himself, telling staff that
he was a clever man and knew how to kill himself. During his time in
healthcare regular reviews of his situation took place and in the days after his
admittance he continued to express thoughts of self harm. However, over time
his mood lifted and his ACCT observations were reduced. On 17 June, he
reported to staff that he was settled, felt well and was happy to be transferred
to one of the prison’s main units, Blackthorn unit. Three days later the ACCT
document was closed.
Little is known of the man’s time on Blackthorn unit. Staff reported that he was
a quiet man who was well behaved, quiet and polite. He appears to have
spent most of his time in his cell and did not mix with other prisoners on the
unit. His personal officer said, “… most of the time you wouldn’t even know he
was here, spends all his time behind his door apart from going on visits”.
Having appeared at court on a number of occasions over the preceding
months, His trial began on 5 January 2009. On 7 January, the man’s solicitor
told staff at Crown Court that the man had said “If you see me tomorrow you
will, if you don’t you won’t”. Staff raised a Suicide Self Harm Warning form
and, when he returned to Bullingdon, he was assessed by one of the reception
nurses. They considered whether an ACCT document should be opened, but
based on his presentation, decided that it was not necessary.
The man returned to court the following day, appearing to be in good spirits
that morning. On his return to the prison that evening he was again reviewed
by a member of healthcare staff, who reported that he was fit and well.
At approximately 5.42am on 9 January, a member of staff found the man lying
on his bed, when his cell was unlocked, having cut his neck. On raising the
alarm, other officers attended along with nursing staff. However, no
resuscitation was attempted as it was evident that he was dead. His death
was confirmed by the prison doctor at 7.30am.
My report on the man’s death makes a number of recommendations, the most
significant of which are highlighted in the clinical review, namely that during the
man’s time at Bullingdon no psychiatric assessment was completed despite the
nature of his alleged crime. In addition to addressing a number of issues
regarding staff entering cells at night, I draw attention to the failure to record
significant events in his wing history sheets. Very little is known of the man
during his time at Bullingdon, highlighting failures in the operation of the
personal officer scheme at the prison.
THE INVESTIGATION PROCESS
1. The investigation following the man’s death was carried out by one of the
Ombudsman’s investigators. He opened the investigation on 14 January
2009 when he visited HMP Bullingdon. He met the Governor of
Bullingdon, the chair of the IMB, and the chair of the Prison Officers
Association. The investigator also met Detective Sergeant C. During the
course of the investigation the investigator provided verbal and written
feedback to the Governor and other members of staff at the prison.
2. Notices announcing the investigation and its terms of reference were
issued to both staff and prisoners at Bullingdon. The notices were
displayed around the prison and invited staff and prisoners to contact the
investigator should they wish to do so. The investigator obtained
documentation relating to the time that the man spent at Bullingdon and
visited the prison on several occasions to conduct interviews with both
staff and prisoners.
3. A clinical review was commissioned from the local Primary Care Trust
(PCT). A copy of the report can be found in Annex 1.
4. One of the Ombudsman’s family liaison officers contacted the man’s
family to discuss the purpose and scope of the investigation and to give
them the opportunity to raise any questions or concerns they had about
his death. The family raised a number of questions when they met the
family liaison officer and the investigator. I hope that this report helps
clarify the family’s concerns and any other issues that remain unclear,
helping them to better understand what happened to the man in the time
leading to his death. Other issues raised by his family but not dealt with
directly in this report have been addressed separately by the investigator
and another of the Ombudsman’s family liaison officer’s who took over
liaison with the family. They include that the man had not had access to
the prison canteen (shop) over the Christmas period, that routine blood
samples went missing and that some of his property was not returned.
5. A copy of this report will be sent to the Coroner to assist him with his
enquiries.
6. At the beginning of September 2009, when my draft report was about to
be published a prisoner at Bullingdon contacted the investigator with
information about the man’s death. In particular the prisoner alleged that
on 8 January, Listeners and Insiders working in reception that evening
were asked to return to their wings early. (Listeners are prisoners trained
by the Samaritans to offer confidential support for prisoners in distress.
They are available 24 hours every day and will meet prisoners to listen to
their concerns. Insiders are also prisoners, who usually work on first night
and induction centres, where they offer guidance and information to new
prisoners. Unlike Listeners, Insiders have no formal training.)
7. The prisoner said that, as a consequence of the Listeners and Insiders
leaving reception early, a number of new prisoners returning from court,
including the man who died, were not seen. The investigator spoke with
the prisoner on the telephone and asked Governor B, Head of Prisoner
Community with responsibility for the Listeners and Insiders, to respond to
the issues raised by the prisoner. I address these matters in the Issues
section of my report at paragraph 93.
HMP BULLINGDON
8. HMP Bullingdon is a category C training prison holding convicted and un-
convicted adult male prisoners. The prison serves the courts in
Oxfordshire and Berkshire.
9. Bullingdon was opened in 1992 and can accommodate up to 1124
prisoners. The prison is made up of six wings or units which are made up
of both single and shared cell accommodation. Four of the units are
made up of three spurs with a fifth, added in 1998, having two spurs. An
additional wing was constructed in 2008 comprising of two spurs
accommodating a first night centre and enhanced prisoners.
10. The prison has a range of work, education and training opportunities
delivering key skills and vocational qualifications. Bullingdon also runs a
number of offender behaviour programmes.
11. Healthcare at the prison is provided by the local Primary Care Trust
(PCT). There is a 24 bed inpatient facility at the prison which is staffed
throughout the day and has two nurses on duty during the night. An
outpatient’s facility delivers a daily triage system referring prisoners to a
doctor as necessary. A doctor is available every weekday and there is an
on-call system during weekends and at night.
12. Since April 2004, when the Ombudsman started investigating all deaths in
custody, he has investigated six self inflicted deaths at Bullingdon,
including this man’s. Four of the reports do not identify any similar issues
to those in this report into his death. However, I note that two
recommendations, made as a consequence of the Ombudsman’s
investigation into the death of a man at the prison in December 2004, are
similar to two in this report. These recommendations relate, firstly, to the
reviewing of night instructions, and ensuring that night staff are aware of
the instructions and their duties and, secondly, to the operation of the
personal officer scheme on Blackthorn unit.
Independent Monitoring Board report
13. The Independent Monitoring Board in their most recent annual report,
2007/2008, said that, despite the pressures caused by the high population
at Bullingdon, the positive improvements made to the treatment of
prisoners and to the regime at the prison had continued.
14. The IMB also reported that there was a sound Assessment, Care in
Custody and Teamwork (ACCT) process in place although it was noted
that the ACCT coordinator was quite stretched at times. The IMB were
pleased to note that, however late it was, newly arrived prisoners were
treated with care and consideration, assessed by healthcare and given a
hot meal by staff. The report observed approvingly that staff were both
hard working and dedicated, ensuring the decent treatment of prisoners in
the reception area.
Her Majesty’s Chief Inspector of Prisons’ report
15. Her Majesty’s Chief Inspector of Prisons carried out an announced
inspection of Bullingdon in January 2008. She reported that, despite
considerable change over recent years, overall the prison was performing
relatively well. She said that it was to the prison’s credit that it had risen
to many of the challenges posed by the complex and diverse demands
placed on it. She was well aware that there was inevitably plenty more
still to do, adding that this should not obscure the progress made, or the
fact that it had been sustained at a time of considerable pressure.
16. However, HM Chief Inspector of Prisons noted that relationships between
staff and prisoners were mixed and, although the interactions that she
observed were good, personal officer work was underdeveloped. She
said entries in personal files were mostly about behaviour and displayed
little awareness of prisoner’s personal and individual circumstances, or
their resettlement objectives. Until recently there had been long gaps in
entries in some files. She found that personal officer entries on Edgcott
unit were noticeably better than the rest of the prison and concluded that
entries in records would be improved by a better functioning personal
officer scheme. (The man who died did not live in Edgcott unit.)
17. HM Chief Inspector of Prisons also reported relatively few incidents of
self-harm. However, she said that delays in receiving investigation
reports from the last deaths in custody, over a year prior to her inspection,
had hampered learning at the prison. She observed that there were some
good examples of multidisciplinary ACCT procedures and high- risk
prisoners on constant watch were well supported by the Mental Health In-
Reach team (MHIRT).
KEY FINDINGS
18. On 26 May 2008, the man who is the subject of this report was charged
with the murder of his wife. After the attack he wounded himself, by
cutting his throat, and was treated in hospital for his injuries. On 2 June,
he appeared at Magistrates’ Court and was remanded into custody at
HMP Bullingdon that afternoon.
19. The Prisoner Escort Form (PER form – a document used by escort staff
to record a prisoner’s known risks and other information) completed by
escort staff noted that the man was at risk of suicide due to the nature of
his offence, that he was low in mood and had been continually observed
whilst in police custody. On his arrival at Bullingdon staff recorded his
personal details, including the details of his next of kin. A Cell Sharing
Risk Assessment (CSRA) indicated that he was, “quite distressed and
unpredictable at the moment. Needs some time to sort his head out”. (A
CSRA is used to assess the risk that a prisoner would present to others
when sharing a cell.)
20. During the reception process Staff Nurse D, Registered General Nurse
(RGN), conducted a first reception health screen on the man. Nurse D
noted on the Egton Medical Information System (EMIS) that an
Assessment, Care in Custody and Teamwork (ACCT) document had
been opened on the man as a consequence of his offence and high
profile. (EMIS is the patient electronic medical record and the ACCT
document is used to assess, observe and support prisoners who are at
risk. It highlights the problems and possible trigger points of a prisoner at
risk of harming themselves and makes a multidisciplinary plan to give
support and help through a period of crisis.) He told Nurse D that he
wished he had not been saved after cutting his throat. It was decided that
he should be placed on a constant watch in the prison’s healthcare unit.
(Unfortunately the ACCT document opened by staff at Bullingdon appears
to have been lost. References to the ACCT document in this report have
been taken from the entries of nursing staff on EMIS.)
21. The next morning, 3 June, the man was seen by Nurse E, Registered
Mental Health Nurse (RMN). He told the nurse that he was thinking about
harming himself again, adding that he would not tell her of his plans as
she would then know as much as he did, adding that he was a clever man
and knew ways to take his life.
22. Later that morning, he was assessed by Dr F, one of the prison doctors.
She too reported the man’s ongoing thoughts of harming himself and said
that he had told her that he was a clever man who new how to kill himself.
He told Dr F about his previous contact with a psychiatrist, after some
marital problems, when he had refused to take the medication which was
prescribed. Dr F noted that the man had not been admitted to a
psychiatric hospital, did not want to take any medication and that there
was no evidence of any psychotic symptoms.
23. During an ACCT review later that day, the man told Nurse E that he
believed in the philosophy of a, “life for life”, and had every intention of
dying. He said that he was not afraid of dying and repeated that he was a
clever man who, “… had ways in which he would be able to do it”. He
remained on a constant watch in the healthcare unit.
24. The man was seen by Dr G, another of the prison doctors, on 4 June. Dr
G recorded on EMIS that he showed no signs of mental illness. However,
in the light of his strong feelings of remorse and in view of his serious
suicide attempt, Dr G took the decision that he should remain on a
continuous watch.
25. During an ACCT review later that day, the man told Nurse E that he
wanted to remain being watched continuously and still thought about
harming himself. Nurse E reported that, although he remained isolated,
he was engaging with staff. That afternoon, he spent time sitting in the
exercise yard reading a book. During the night the man told Nurse H that
it was stupid to leave a plastic knife in his cell as he could break it and
use it to harm himself. The cutlery was removed and Nurse H noted that
she felt the man was letting her know that he was still thinking of harming
himself.
26. Throughout his time on the healthcare unit, the man’s neck injuries were
treated. On 5 June, after an examination by Dr F, the staples (sutures)
used to heal his neck injuries were removed. Later that day the man was
seen again by Dr G. He noted in EMIS that the man denied any active
suicidal thoughts, but had said that his feelings remained unstable, adding
that he would just have to take every day as it came.
27. Over the following days he remained on constant observations and took
part in frequent ACCT reviews. During one such review, following a visit
by his brother on 5 June, he was said to have avoided eye contact with
staff. However, when seen by Dr G the following day, the man, although
subdued, expressed no thoughts of harming himself. Dr G noted on
EMIS that, in view of his fairly controlled and calm character, it was
difficult to assess his suicide risk. The ACCT review on 8 June decided
that he should be continuously observed, due to his appearance at court
the following day.
28. On 9 June, the man appeared at Crown Court. On his return to
Bullingdon, Nurse D noted on EMIS that he appeared settled. Although
there were no issues to report, he remained on constant observation. At
an ACCT review the next day, 10 June, he told staff that he felt much
more positive, could see a future and had no current or recent thoughts of
harming himself. It was agreed with Dr G that the continual observation
of Russell could come to an end and be replaced by half hourly
observations.
29. At an ACCT review on 11 June, the man said that he was fine and felt
great, though Nurse E noted his mood as being slightly high. He spent a
lot of time reading in the healthcare unit garden and there were no
significant concerns at the time. Because he remained settled over the
following days, spending most of his time reading in his cell and keeping
himself to himself, the ACCT monitoring was reduced to hourly
observations.
30. During a review with Dr F on 17 June, the man reported feeling well and
settled, saying that he would be happy to be transferred to one of the
prison’s main units. A discharge sheet was prepared and, later that day,
he transferred to Blackthorn unit, the remand unit in the prison. A CSRA
completed by SO I, noted that the man was currently subject to an open
ACCT and being observed every hour. SO I provided him with a brief
induction to Blackthorn unit and he was told that his personal officers
would be Officer J and Officer K.
31. On 20 June, Russell’s ACCT document was closed. (Due to the missing
ACCT document I have been unable to review the considerations made
by staff when closing the ACCT. However the Safer Custody Manager,
has confirmed that a post closure interview did take place.)
32. Officer J, the man’s personal officer, wrote in his wing history sheets on
19 July, that during the short time he had been on the unit he had been
polite and well behaved and had expressed no concerns.
33. The man attended court again on 4 August. On 8 September, Officer J
wrote that the man continued to be well behaved and polite, spending
most of his time in his cell and did not mix with his peers. On 25 October,
Officer J wrote that the man, “… continues to be well behaved, most of
the time you wouldn’t even know he was here, spends all his time behind
his door apart from when going to visits”.
34. During November and December, he reported to healthcare for a number
of tests and was seen by Dr F. In the clinical review, the clinical reviewer
notes that on 12 November, he was seen by Dr F regarding a painful right
shoulder and was prescribed anti-inflammatory medication and routine
blood tests were taken. During this time there was no indication to
nursing staff that he had attempted or expressed any thoughts of harming
himself.
35. On 2 December, Officer L wrote in t he man’s wing history sheets that he
had recently moved to another (single) cell on the unit and had no issues.
(The investigator was unable to establish the reason for the move.) It was
suggested to him that he might want to get a job in the prison to keep
himself occupied. However, Officer L noted that he was not keen on the
idea and that he sat in his cell most of the time. (Remand prisoners are
not required to work whilst they are in prison custody.)
In response to the draft report the man’s family said that they had been
told by the man when visiting him at Bullingdon that he had been moved
from his original cell for not giving a urine sample in front of prison
officer’s but he was willing for the to take a blood sample. After this
incident they say that he was moved to another cell.
36. Following a number of court appearances since 2 June, the man’s trial
commenced on 5 January 2009 at Crown Court. The PER form used for
his transfer to court indicated that he was on trial for murder and that his
last ACCT document had been closed on 20 June 2008. The PER form
noted that he was both vulnerable and at risk of harming himself. On his
return from court he was seen by Nurse M who noted on EMIS, “Returned
from court, states fit and well, no issues reported.”
37. A prisoner on Blackthorn unit, told the police that he had known the man
who died for about four months, adding that the man only spoke with him
and his brother. He said that the man would stay in his cell for many
hours and not socialise with other prisoners, but appeared to be dealing
with prison life. He said that he last saw and spoke with the man on 3
January during visits, when he appeared normal and did not appear to be
down or depressed.
38. The man who died went to court for the second day of his trial on 6
January. There is no indication either in EMIS or on his wing history
sheets that he was assessed by a member of healthcare on his return.
39. The man attended court again on 7 January. In a statement to the police
the practice manager for the man’s Solicitors, said that after a legal visit,
at around 4.45pm, he told Prisoner Custody Officer (PCO) N and PCO O
that the man had said, “If you see me tomorrow you will, if you don’t you
won’t.” In his statement to police, PCO N said that the practice manager
told himself and PCO O that he was concerned about the man’s
comments and felt that they ought to know.
40. PCO N said he was aware that the man had previously been on an ACCT
document and so he asked PCO O to raise a Suicide Self Harm Warning
form. (The prison was unable to provide a copy of the Suicide Self Harm
Warning form. However, the police obtained a copy of the document from
Reliance, the prison escort contractor.) On the form PCO O had indicated
that the man seemed very depressed and so had been monitored
intermittently. PCO O said that he telephoned Bullingdon advising them
of the situation and reported that a Suicide Self Harm Warning form had
been opened.
41. The man returned to Bullingdon at 6.15pm. Officer P said that he booked
him in and briefly asked him if he was okay, which he confirmed. Officer
P said he was given a meal and put in one of the holding cells. Officer P
told the investigator that he had no immediate concerns about his welfare.
The officer said that he alerted Nurse Q, Senior RGN, explaining that the
man had just returned from court on a Suicide Self Harm Warning form
and asking if he could be prioritised by healthcare. Later that evening
Officer P asked Nurse Q if the man was okay and Nurse Q confirmed that
he was fine.
42. Sister R, RGN, told police that during the afternoon of 7 January, she
learnt that court staff had contacted Bullingdon reception staff, advising
that they were concerned about the man and that a Suicide Self Harm
Warning form had been raised. When he returned to Bullingdon Sister R
wrote on the PER form that she had seen the Suicide Self Harm Warning
form. Sister R discussed the man with Nurse Q and they decided that
Nurse Q would speak with him to assess him. Sister R said that she also
spoke with Nurse Q later that evening. Nurse Q told her that he had no
concerns about the man and confirmed that he could return to Blackthorn
unit.
43. On the copy of the Suicide Self Harm Warning form, obtained by the
police, sections seven and eight, details of reception officer and
confirmation of action taken by healthcare screener, are incomplete.
During interview Officer P told the investigator that he was certain he had
signed the form, as did Nurse Q. Given that Bullingdon’s copy of the form
is missing, the investigator was unable to establish whether or not the
form was signed by Officer P and Nurse Q. Sister R informed the
investigator that, although she had had no verbal contact with the man
that afternoon, she saw Nurse Q sign the Suicide Self Harm Warning
form.
44. Nurse Q told police that he spoke with the man briefly in the holding cell,
asking him if he was okay. He said that he did not have an in-depth
conversation with him at this stage because other prisoners were present.
Nurse Q said he read the Suicide Self Harm Warning form and spoke to
SO P before calling the man through to the nurse’s interview room. Nurse
Q told police that the man told him he had had a tough day. He claimed
that he had not meant anything by what he had said to the solicitor
practice manager in court, though he added that he did “fancy a lie in”.
Nurse Q told the police that the man was polite and behaved
appropriately, assuring him that he had no thoughts of harming himself.
He had no concerns about him, who assured him that he would speak to
staff and other prisoners if he needed to. Nurse Q reminded the man
about the Listeners scheme and how to access it. (Listeners are
prisoners trained by the Samaritans to offer confidential support for
prisoners in distress. They are available 24 hours every day and will
meet prisoners to listen to their concerns.) On leaving the interview room
the man gave Nurse Q a slap on the back, telling him that he was fine.
Nurse Q said that he saw the man the next evening in reception but did
not speak with him, saying that there was no indication that anything was
amiss.
45. Nurse Q noted on EMIS that the man made no specific reference to
harming himself or having any suicidal intentions. Nurse Q wrote that,
when asked about the comments made at court, the man said:
“… YES it had been a tough day but he didn’t mean anything by what
he had said. He said that he did fancy a lie in though!!!!!!!!! He was
polite and appropriate and assured me that he had no thoughts of self
harm. When asked he also assured me that if he did start to struggle he
would talk to someone. He said that he had people on the Wing he could
talk to, both prisoners and staff. I reminded him about the Listeners
system too, if he needed to make use of it. No concerns raised at this
time.”
Nurse Q did not enter any of his interaction with the man that afternoon in
the wing history sheets, including that he judged him fit to return to
Blackthorn unit.
46. The man went back to court the following day, 8 January. The PER form
noted that he was at risk of suicide/self harm and had previously been on
an ACCT document. He returned from court at 6.20pm. Officer P was
again on duty in reception that evening. He said that there were no
issues that day were brought to his attention and no healthcare issues
were reported.
47. One of the unit officers, Officer S, unlocked the man’s cell so that he
could go to court on 8 January and the preceding days. He said that
during this time he appeared to be in good spirits and showed no signs of
someone likely to take his own life. Officer T, who had also unlocked the
man for court over the previous three days, described him as polite and
compliant, never giving cause for concern.
48. The man was reviewed by Healthcare Assistant Ms U, who although she
had received training, was working for the first time on her own in
reception that evening. She noted on EMIS at 7.04pm, “Returned from
Court. Trial continuing. States fit and well”. Ms U also wrote in his wing
history sheets that he had been seen by healthcare staff. She told the
investigator that he appeared relaxed saying that, “… he didn’t appear
anxious or upset or anything, he just said he was fine”. Ms U told the
investigator that when she assessed him she did not refer to previous
entries on EMIS, not having access to a terminal. She said that any notes
about her assessment of a prisoner would be made later on EMIS when
she had the opportunity.
49. In the week before his death, the man spoke to another prisoner on
Blackthorn unit. The prisoner told the police that they discussed his court
case and his fear that it was going against him. The prisoner said that the
man kept himself to himself, staying in his cell most of the time. He
thought that the man found it difficult to speak with people. The prisoner
said that, during the week of his trial, the man seemed to be a bit low. He
last saw the man when he returned to the wing on 8 January.
50. Officer V had a brief conversation with the man who died when he locked
his cell up that night at about 8.00pm. Officer V told the police that he
had known him for a number of months on the wing and he seemed no
different that night from usual. Officer V asked him if he was alright. He
said that although he admitted he was a little tired as he had to get up
early for court, he did not appear down or depressed. Officer V said that
he kept himself to himself and did not socialise with other prisoners,
preferring to stay in his cell. He believed that if he had any problems he
would have alerted staff. Officer V told the police that he believed that the
ACCT document had been closed before the man arrived on Blackthorn
unit, as he could not recall making an entry in it.
51. Another prisoner told the police that at approximately 8.00pm on 8
January, he spoke with the man when he got back from court about
closing his cell door. He said that he seemed happy at that time and
thanked him for closing his cell door. The prisoner also added that the
man appeared no different from normal. He said the man:
“… kept himself to himself and didn’t socialise with other prisoners, he
didn’t come out of his cell that much. In the times I had occasion to speak
with him he never seemed down or depressed he was just getting on with
his remand period.”
52. In a letter postmarked 9 January 2009, the man who died wrote to his
solicitors, thanking them for their assistance and stating his innocence of
his wife’s murder.
53. At around 5.30am on 9 January, Operational Support Grade (OSG) W
was completing his night duties, part of which involved waking prisoners
who were to attend court that day. OSG W said that he left the man till
last, as on the previous few mornings, he had already been up making
tea. OSG W told the investigator that when he arrived at his cell at
5.42am he saw him:
“ … lying on the bed, his arm hanging over. And I knocked on the
door, called out his name, saw no movement. I banged on the door, and
you rattle it by the handle, and I watched and he never moved at all.
Then I actually gathered a few more kicks just to make sure; never saw
any movement. And I stepped right up to the glass and put my eye right
against the glass to look in, to see what I could see. And all I could see
was a stain on the floor, it could have been water but you know
straightaway you know there’s something wrong because he should have
been up; he was up every other morning. So I presumed that it was blood
and I called Oscar 1, Bravo1 (which is myself), Level 1, which makes him
know that it’s something very serious. And then I ran upstairs and I could
hear him running along the passage. This was, I think I put the call out at
5.46am.”
54. OSG W told the investigator that he persisted in trying to obtain a
response from the man, trying to wake him up for three or four minutes
before raising the alarm. OSG W said:
“You’ve got to make sure they’re awake. You see I can’t call Level 1
[The emergency response code] unless I’m sure there’s something
wrong. So I’ve got to really hammer at the door. Some of these guys
sleep very heavily and you’ve got to bang the door to get them to answer
you.”
OSG W said that he realised that there was something wrong when he
noticed a stain on the floor and used his radio to make an emergency call
for further assistance. He then made his way to the centre office, on the
landing above, to await the arrival of assistance.
55. Senior Officer (SO) X was the night orderly officer (Oscar1), the most
senior officer on duty in the prison. He had an assistant night orderly
officer, Officer S (Oscar 2). SO X had just left his office and was walking
towards the house blocks with Officer S and Officer T. At 5.46am, the
communications room log records, OSG W made an emergency Level 1
call for him to attend Blackthorn unit immediately. (The emergency Level
1 call alerts staff to a life threatening incident or event). As the officers
responded SO X asked Officer Y, who was also in the vicinity, to collect
the nurses from the healthcare Unit. (Nurses do not carry keys at night
for security reasons and rely on prison staff to unlock the gates for them
in emergencies.)
56. On their arrival on Blackthorn unit at 5.48am, the officers were directed by
OSG W to the man’s cell on the landing below. Officer T arrived at the
cell first and, looking through the cell observation flap, saw the man lying
on the bed with his right arm under his body. His head was turned to the
left and his arm was hanging down. There was a pool of blood on the cell
floor. Officer T went into the cell, followed by SO X and Officer S. SO X
tried to obtain a response from the man, but there was none. Officer Z
arrived on the wing as SO X, Officer T and Officer S were leaving the cell.
SO X said he let Nurse A RGN, and Nurse B RGN, into the cell at
5.58am. All of the officers believed that the man was already dead.
57. Officer Y, who had been instructed by SO X to collect and escort the
nurses from the healthcare unit to Blackthorn unit, told the investigator
that she proceeded to healthcare, arriving two to three minutes after the
alarm had been raised.
58. Nurse A, who was working in the healthcare unit, heard OSG W call a
Level 1 emergency code. In her incident statement Nurse A said that she
collected the emergency equipment and arrived at the man’s cell at about
5.58pm along with her colleague Nurse B. They went into the cell to
assess the man. They agreed that there were no signs of life and that
nothing further could be done to save him. Resuscitation was not
attempted. In the clinical review it says that the decision not to attempt
resuscitation was appropriate and that the information to support this was
clear and well documented.
59. The ambulance service received an emergency call to go to Bullingdon at
5.54am, arriving at 6.19am. My investigator has been unable to ascertain
with any certainty who made the request for the ambulance to attend.
The man was pronounced dead by one of the prison doctors at 7.30am.
60. I understand that a blade taken from a razor and a letter were found in the
man’s cell and were removed by the police.
61. The staff who discovered the man and responded to the emergency were
invited to a hot-debrief. (A hot-debrief is a meeting held as soon as
possible after a major incident.) A review of prisoners at risk of harming
themselves was completed by staff. I also understand that the officers
and staff involved in the incident were approached by the care and
welfare team. Several officers said during interview that they felt the care
offered was beneficial, supportive and helpful.
62. The man’s family were told of his death by Gov A, Chaplain C and
Governor D that morning.
ISSUES
Psychiatric assessment
63. Because the man who died had been charged with murder, and because
of the wounds he made to his neck before his arrest, he was considered
to be at a high risk of harming himself and so was monitored constantly
by staff whilst he was in police custody. On transferring to Bullingdon, he
continued to be observed constantly for over a week in the prison’s
healthcare unit.
64. In the clinical review, the clinical reviewer concluded that the ACCT
document was managed sensitively, according to the medical records
available, and was appropriate. The clinical reviewer’s opinion was that
the gradual reduction in levels of observations and the man’s return to the
main prison were well judged. The clinical reviewer said:
“At all times the man was treated with care, concern, and
professionalism and judgements made about his risk of self-harm appear
to have been thoughtful and carefully considered.”
65. The clinical reviewer observed that, although there was nothing to
suggest that the man was suffering from any psychotic illness:
“… in a less secure environment, i.e. not in prison, a man with such
clear suicidal ideation would have been referred for a psychiatric
assessment. Such an assessment might have revealed further insights
regarding his mental state, or instigated different follow-up that could have
helped him, and might have influenced his management at the time of his
trial and successful suicide attempt.”
In his clinical review, the clinical reviewer recommended that,
Prisoners alleged to have committed a violent murder, who have
violently attempted to take their own life and who express suicidal
ideas should be referred to the Forensic Psychiatry Team.
The clinical reviewer said that such action would provide further specialist
assessment, and ongoing support, both for the prisoner and for the
Primary Health Care Team. I agree with his findings and endorse his
recommendation.
Missing ACCT and Suicide Self Harm Warning Form
66. During the investigation the investigator was advised by staff at
Bullingdon that both the ACCT document opened on the man’s arrival at
the prison and the Suicide Self Harm Warning form raised at court just
two days before his death had been lost. The loss of these documents is
extremely regrettable and concerning.
67. The loss of the ACCT document means that I am unable to make a
considered judgement about the actions and observations by staff during
the three weeks it was open. However, thanks to the quality entries made
in EMIS by Nurse E, the investigator was able to discover that the man’s
ACCT document was reviewed frequently.
68. The disappearance of the ACCT also meant that the investigator was
unable to establish what actions were taken by wing staff after Russell
transferred to Blackthorn unit on 17 June, and the reasons and
consideration behind the closure of the ACCT three days later on 20
June.
69. Additionally Bullingdon was unable to provide the investigator with a still
more important document, the Suicide Self Harm Warning form opened
by escort staff at Crown Court on the afternoon of 7 January. However,
the investigator was given a copy of the document by the police, who
obtained it from Reliance, the prison escorts contractor.
70. The investigator asked the Safer Custody Manager what should happen
to a Suicide Self Harm Warning form when it arrives at reception with a
prisoner. She said that when a prisoner comes in with a warning form and
an ACCT is not opened, the top white copy of the form should be placed
in the prisoner’s medical record and the yellow copy filed with the wing
history sheet to alert staff on the wings that a warning form had been
raised. I have found no copies of the form in the documents identified by
the Safer Custody manager and I therefore conclude that the correct
process was not followed on 7 January.
71. I am concerned whenever documentation in prisons goes missing.
However, I am particularly alarmed on this occasion that documents as
important as the ACCT and Suicide Self Harm Warning form have both
disappeared. I accordingly make the following recommendation.
The Governor should remind all staff of the importance of treating all
documents, and in particular those relating to a prisoner’s risk of
harming himself, with care. The Governor should ensure that all
such documents are processed and filed correctly by staff.
Wing history sheets
72. As with so many of the investigations completed by the Ombudsman’s
office I am obliged to comment on the lack of quality entries in the man’s
wing history sheets. During the investigation the investigator was unable
to establish any detail about the time that the man spent in custody at
Bullingdon and, as a consequence, I am unable to answer fully many of
the questions asked by his family. I note that only four significant entries
were made by staff between the date of his location on Blackthorn unit on
17 June and the start of his trial seven months later on 5 January 2009.
73. In addition to a lack of general weekly entries and observations about the
man, staff on Blackthorn unit also failed to make entries in his wing history
sheets about several significant events that occurred during his period on
remand. There was no reference to closure of the ACCT document on 20
June, or to the post closure interview that subsequently took place.
Additionally, neither reception nor healthcare staff referred to the Suicide
Self Harm Warning form opened on 7 January, and after his return from
court on 6 and 7 January, healthcare staff failed to note that he had been
assessed as fit for normal location.
74. It saddens me that prisoners such as the man who died, who present no
trouble and remain under the “radar” of most prison staff, go unnoticed
and as a consequence less is recorded about them. This leads me to
conclude that they have equally less interaction with staff.
In response to the draft report the Prison Service wrote: “There is no
evidence to suggest that it was defiantly the case that the man was not
noticed by staff.”
75. Bullingdon’s own personal officer scheme expects a minimum of one
quality entry in a prisoner’s history sheets at least once every two weeks.
(The investigator was unable to establish who his personal officer was at
the time of his death. Although Officer J and Officer K were assigned as
his personal officers when he first arrived on Blackthorn unit, after his
movement to another cell it is not clear who the allocated personal officer
was.) I would also expect any significant events and entries to be
highlighted in the unit’s observation book. The absence of staff entries in
his wing history sheets and the unit observation book clearly prevented
their colleagues from accessing important information about him.
The Governor should remind all staff of the importance of
completing wing history sheets and observation books, noting their
interactions with prisoners and other pertinent information.
The Governor should satisfy himself that the Personal Officer
Scheme is operating effectively and in accordance with the local
protocol.
The man’s return from court on 7 and 8 January
76. Shortly before the man’s return from court to Bullingdon on the afternoon
of 7 January, Reliance prisoner custody officers opened a Suicide Self
Harm Warning form because of comments made by him to his legal
representative. In addition, the prisoner custody officers telephoned
reception staff at Bullingdon to advise them of the situation.
77. The investigator established that, on his arrival at Bullingdon, staff in
reception were aware of the Suicide Self Harm Warning form that had
been opened. Officer P asked him how he was felt on his return to the
prison. Soon afterwards he was assessed by Nurse Q as to whether or
not an ACCT document should be opened. The nurse decided that
opening an ACCT document was not required.
78. With the benefit of hindsight it would be easy to conclude that Nurse Q
should have opened an ACCT. However, Nurse Q made a significant and
detailed entry on EMIS about his assessment of the man. I am satisfied
that Nurse Q made a full and considered assessment about whether or
not to open an ACCT document based on the man’s presentation,
assurances and his responses to questioning. In his clinical review, the
clinical reviewer also noted, with regard to the man’s contact with Nurse
Q, that:
“The notes are appropriate, appear contemporaneous, and clearly
reflect an appropriate conversation on which the judgement that no
additional intervention was needed at the time was made.”
79. No issues were raised by staff, either at court or on the man’s return to
prison the following evening, 8 January. Ms U, who assessed the man
that evening, said that he appeared relaxed and claimed that he was fine.
However, she added that she had not been aware that he had come into
the prison the previous evening on a Suicide Self Harm Warning form.
Ms U did not have access to EMIS when she was reviewing prisoners.
She said that, had she known about the warning form, she might have
reached a different conclusion.
I recommend that all nurses have access to EMIS during reception
screening so that they can review previous entries and enter the
notes of their assessment at the time of the interview.
80. Prison Service Order (PSO) 2700 provides guidance on Suicide and Self
Harm Prevention. The PSO highlights in section 4.10 that prisoners
charged with murder and/or sentenced to life are at a higher risk of
suicide than other prisoners. The PSO says that the care of such
prisoners requires close monitoring of trigger points such as trials and
sentencing.
81. In his clinical review the clinical reviewer concludes that it was highly
probable that, having determined to take his own life, no intervention
would have stopped him from doing so. However, he goes on to say that,
in hindsight and in the context of his previous serious attempt to harm
himself after the offence with which he was charged, and the stress of his
court appearances, there remained the possibility that closer observation
of the man might have altered the outcome.
82. The clinical reviewer recommends that when a prisoner is identified as
being at a heightened risk of self harm, such as when a Suicide Self Harm
Warning form is opened during trial, consideration should be given to a
more formal reception process for men returning from court so that any
change in their mental state can be detected. The clinical reviewer,
appreciating the many prisoners moving in and out of prison every day,
suggests that EMIS could be used to identify those prisoners who might
benefit. I agree with his findings and recommend that:
The Governor and Healthcare Manager should consider introducing
a more formalised reception process for prisoners returning from
court who are identified as at risk of self harm.
Raising the alarm and going into the man’s cell
83. OSG W went to wake the man at 5.42am ready for him to go to court.
Unable to obtain a response and noticing a stain on the floor, he radioed
for emergency assistance at 5.46am. OSG W did go in to the man’s cell,
but returned to the wing office on the landing above to await the arrival of
other officers. My investigator asked OSG W if there was any reason why
he did not enter the cell immediately upon discovering the man. OSG W
replied:
“Well there’s no reason for me to enter the cell. Its not part of my
duties to start with; the cell only gets entered by an officer accompanied
with a couple of other officers. They train in case they go into a cell and
someone attacked them; they’re trained for that, I’m not. So it’s got
nothing, as I say to do with me.”
84. It was apparent to the investigator from his interview with OSG W that he
was unaware of the local procedures to be followed regarding entering a
cell at night in response to a suspected death or similar emergency. OSG
W was also unclear as to the circumstances regarding when to enter a
cell at night and the use of the emergency cell key, which is carried by all
OSGs. OSG W said he was not aware of any circumstances or
instructions to enter a cell. He believed that it was for the orderly officer
to assess the situation and decide whether to enter or not. The OSG said
he had been told in training never to enter a cell on his own and had not
been trained to do so. When asked if he was aware of any instructions
explaining the duties of the OSG during the night, OSG W acknowledged
that there might be one, but indicated that he had never referred to it.
OSG W told police that it was the role of the officers to enter the cell to
see what the problem was.
The Governor should ensure that all Operational Support Grades
and other staff working night duties are aware of their roles and
responsibilities, especially regarding going into cells in the event of
an emergency.
85. The investigator obtained the Night Folder containing various instructions
and guidance for OSGs working during the night, and I have also had an
opportunity to review these instructions. I believe that Local Instruction
2.79, Nights – Opening Cells published on 1 August 2008, lacks clarity in
explaining the procedures to be followed in the event of opening a cell at
night, the circumstances in which the cell can be opened by a single
officer and the circumstances such as a fire or a suicide attempt.
86. Similarly Local Instruction 2.89 Nights – Death in Custody/Suspected
Death in Custody, also published on 1 August 2008, is unclear with
regard to the procedures to be followed by staff who discover a death in
custody. In particular, the instruction lacks guidance as to when a cell
should be entered and the action to be taken upon discovering a prisoner
in distress.
87. Although I appreciate that the Night Folder for OSGs does cover some of
these issues in other documents, I believe a more structured set of night
instructions and guidance would benefit all night staff.
The Governor should review Bullingdon’s night instructions and
other guidance for OSGs contained in the Night Folders. Particular
attention should be focused on those procedures relating to the
discovery of a death or suspected death, when a cell can be
unlocked and the staffing level that is required to do so. The
Governor should ensure that all night staff are aware of these
instructions.
Delay calling an ambulance
88. The ambulance was not called until 5.54am, six minutes after the
responding officers arrived on the unit. The investigator made enquiries
as to who authorises the call for an ambulance in an emergency and
when this is done. When asked if an ambulance should be called as soon
as a Level 1 emergency call is made, Officer T said,
“No, the Orderly Officer will call the ambulance … on assessment of
the situation and from advice from the healthcare staff and nurses he will
then call the ambulance …”
SO X said that an ambulance would not automatically be requested for a
Level 1 call, confirming that the orderly officer would attend and assess
the situation before hand. Officer S also said that an investigation and
assessment of a Level 1 response is made before an ambulance is
called.
89. It is essential that ambulances are called immediately to situations such
as a Level 1 emergency call when there is a serious threat to life. Relying
on the night orderly officer’s assessment before calling an ambulance will
undoubtedly cause considerable delay and any such delay. Any delay
can have a significant impact on a person’s chances of survival. The
ambulance can always be cancelled at a later time. A letter to Governors
from the Director of Prison Health in March 2004 advised that it was their
responsibility to ensure a protocol existed to facilitate immediate access
to the paramedic services. The letter advises that:
“It is also essential that internal procedures should not waste undue
time in summoning emergency assistance. It should not; for example, be
a requirement in every case for a member of the Health Care Team to
attend the scene before Emergency Services are called. However, a
subsequent 999 call to the Ambulance Service should be made to cancel
the response if, after the original 999 call has been made, a member of
the Health Care Team arrives with the patient and deems that an
emergency ambulance response is not required.”
The Governor and Healthcare Manager should ensure that a local
protocol is in place that provides clear advice about how and when
the Ambulance Service should be called.
Delay by nursing staff reaching the man’s cell
90. Nursing staff who were on the healthcare unit when the emergency call
for assistance was made did not reach the man’s cell until 5.58am. The
investigator made enquiries about the apparent delay of 12 minutes
before healthcare staff reached the cell. Officer Y, the escorting officer,
said that she could not recall any delay, adding that it was a Level 1 and
that all staff knew of the severity of the emergency. She said that nursing
staff collected the emergency packs immediately and she then escorted
them to Blackthorn unit. Officer Y said that this would have taken no
longer than a couple of minutes. When asked a similar question by the
investigator, Nurse A said that she too could not recall a delay in
responding to the emergency call. Nurse A assumed that the discrepancy
in time was due to the incorrect synchronisation of clocks and watches.
Nurse A asserted that there was definitely no delay between the nurses’
response to the emergency alarm being raised and their arrival at the
man’s cell.
Response codes
91. Although the nurses were aware that they were responding to a Level 1
emergency, the most serious of emergency calls, they were not aware of
the specific nature of the emergency that they were attending. Although I
appreciate that there are no mandatory requirements to use any specific
emergency code system, many prisons use a call system such as red (for
blood loss) and blue (for breathing difficulties). The codes inform staff of
the nature of an emergency in language that is easily understood. I make
no formal recommendation, but I invite the Governor to consider a review
of the code system for emergency calls.
Healthcare record keeping
92. In his clinical review, the clinical reviewer noted that,
“The quality of the nursing and medical notes is by far the best I have
encountered in undertaking a clinical review, and the medical and
nursing staff should be commended regarding such an improvement.
Listeners and Insiders
93. One of the prisoner’s at Bullingdon, who worked as an Insider in reception
said that on 8 January, the Listeners and Insiders were returned to the
wings before all the prisoners had been seen. He said that he protested
and asked to see a member of the Suicide Prevention and Self Harm
Management Team. He said that Governor B saw him a week or so later
to discuss his concern that Listeners and Insiders were repeatedly sent
back to the wings early without seeing all the new arrivals in reception.
The prisoner said that he stated strongly to Governor B that the man’s
death could possibly have been prevented. The prisoner said:
“I stated that while it’s not clear that anything that I or the Listener on
duty could have said or done anything to prevent him from taking his own
life, the opportunity to do so was not allowed us. The Listener or I may
have recognised enough signs to warrant enough concern to report them
to staff.”
94. The investigator put the prisoner’s concerns to Governor B. Governor B
said she was unable to confirm whether the prisoner was working on the
evening of 8 January, whether the Listeners and Insiders were returned to
the wings early that day or whether the man had developed a supportive
relationship with the prisoner. Governor B said, “At no time during any
conversation with the prisoner did he register any concern with me about
the lack of Insiders in Reception being linked to the death of the man.”
Governor B added that:
“I am confident if the prisoner had expressed these concerns to either
of us [the Safer Custody Manager] that we would have taken him
seriously and investigated his concerns thoroughly and promptly.”
Governor B said that she was approached by the prisoner about his
concerns and, having addressed the situation with the Reception Principal
Officer, was satisfied that the matter was rectified and the issue had not
been raised again. Governor B said:
“I have no further recollections of this being raised with me as a
concern or issue and am confident that the Insiders are now firmly
embedded along with Listeners in the Reception and First Night
processes.”
95. Having reviewed the prisoner’s concerns and Governor B’s response, I
cannot confirm whether or not the man was seen by either a Listener or
an Insider on the evening of 8 January. However, Governor B has
confirmed that around January 2009 there was a problem with Listeners
and Insiders being returned to the wings and that this had now been
rectified. It is clear that the man was aware of the scheme, having been
reminded of it during his assessment by Nurse Q on the evening of 7
January.
96. I appreciate the prisoner’s concern and am grateful to him for drawing it to
my attention. However, given the lack of substantive evidence, I am
unable to say whether the absence of Listeners and Insiders in reception
that evening led to the man taking his life, or indeed if it was a
contributory factor.
CONCLUSION
97. On the man’s arrival at Bullingdon from police custody, staff immediately
identified that he was actively suicidal. The support and care that he
received during his first week of custody in the healthcare unit were
described by the clinical reviewer as demonstrating care, concern and
professionalism. However, the man was not referred for a psychiatric
assessment. It is evident that when he was moved to Blackthorn unit he
had little involvement in prison life, preferring to remain in his own cell.
Staff interaction with him was seldom recorded and consequently little is
known of his time on the unit.
98. The man’s circumstances reflected some of the characteristics of a
prisoner at high risk of harming himself. He was facing trial for murder,
his victim was his wife and he had attempted to take his own life at the
time of the alleged offence. However, given his appearance to staff in the
days leading to his death, and in particular during the assessment made
by Nurse Q. I am satisfied that the man had made up his mind to end his
life and convinced the nurse that he was fit and well. I do not believe that
staff could have foreseen what he was about to do.
RECOMMENDATIONS
1. Prisoners alleged to have committed a violent murder, who have violently
attempted to take their own life and who express suicidal ideas should be
referred to the Forensic Psychiatry Team.
Partially Accepted – Referrals to forensic psychiatry would only happen
if when the crime was committed there were mental health concerns. We
have a stepped care system for mental health. We hold regular review
meetings to discuss clients for referral to forensic psychiatry involving our
mental health teams.
2. The Governor should remind all staff of the importance of treating all
documents, and in particular those relating to a prisoner’s risk of harming
himself, with care. The Governor should ensure that all such documents
are processed and filed correctly by staff.
Accepted – A notice to staff will be periodically issued to remind all staff
of the importance of handling all documentation appropriately.
3. The Governor should remind all staff of the importance of completing wing
history sheets and observation books, noting their interactions with
prisoners and other pertinent information.
Accepted – A notice to staff will be issued on a regular basis to ensure
that staff and managers remain vigilant when entering details in case
notes (replaces history sheets) and observation books.
4. The Governor should satisfy himself that the Personal Officer Scheme is
operating effectively and in accordance with the local protocol.
Accepted – The personal officer policy was reviewed in 2009 and is due
for a review again in January 2010. Management checks of this will
establish how well this scheme is working.
5. I recommend that all nurses have access to EMIS during reception
screening so that they can review previous entries and enter the notes of
their assessment at the time of the interview.
Accepted – This is now in place.
6. The Governor and Healthcare Manager should consider introducing a
more formalised reception process for prisoners returning from court who
are identified as at risk of self harm.
Partially Accepted – Formal processes for assessment are in place.
Assessments are carried out in conjunction with the ACCT process.
7. The Governor should ensure that all Operational Support Grades and
other staff working night duties are aware of their roles and
responsibilities, especially regarding going into cells in the event of an
emergency.
Accepted – A notice to staff was issued shortly after the death of the man
to remind the relevant staff of their duties however this will be reissued in
light of this report.
8. The Governor should review Bullingdon’s night instructions and other
guidance for OSGs contained in the Night Folders. Particular attention
should be focused on those procedures relating to the discovery of a
death or suspected death, when a cell can be unlocked and the staffing
level that is required to do so. The Governor should ensure that all night
staff are aware of these instructions.
Accepted – This work is currently underway.
9. The Governor and Healthcare Manager should ensure that a local
protocol is in place that provides clear advice about how and when the
Ambulance Service should be called.
Partially Accepted – Formal process exist however these will be
reissued to all staff to ensure consistence of approach no mater what the
time of day.