Individual at Liverpool

Investigation into the circumstances surrounding the
death of a man
at HMP Liverpool in February 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
This report considers the circumstances surrounding the death of a man at
HMP Liverpool in February 2010. He was found hanging in his cell around
5.20am. He was 53 years old.
I offer my sincere condolences to the man’s family and all those who knew
him.
The investigation was conducted by two investigators on my behalf. I would
like to thank the governing Governors for their co-operation. I also extend
thanks to the liaison for the Ombudsman’s office. In addition, I thank the
clinical reviewer who conducted a review of the man’s clinical care. She was
appointed by the local Primary Care Trust.
The man had served a number of custodial sentences in the past, some of
them at Liverpool. After being remanded into Liverpool in August 2009, he
remained on the same wing until his death. The members of staff who were
involved with him did not think he was at risk.
This is the 15th apparently self-inflicted death at Liverpool since 2004, when
the Ombudsman’s office began investigating all deaths in custody. Before the
man’s death, the last such death occurred in February 2009.
Despite the tragic outcome, there was little to suggest that the man was at risk
of suicide. I have looked into the immediate response, communication,
clinical issues and post-incident care for staff. I make two recommendations
and endorse a further five recommendations made by the clinical reviewer.
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
CONTENTS
Summary
The investigation process
HMP Liverpool
Key findings
Issues
Immediate response
Clinical issues
Communication
Post-incident care for staff
Conclusion
Recommendations
SUMMARY
The man appeared at Magistrates’ Court and was remanded to HMP
Liverpool on 8 August 2009. He was seen by a nurse for an initial health
screening, and then by a locum doctor. It was noted that, before being
remanded into custody, he was drinking heavily on a daily basis. He was
prescribed Chlordiazepoxide (commonly known as Librium) for alcohol
withdrawal, and referred to the prison’s drug dependency unit (DDU). The
doctor who saw him also noted that he suffered from epilepsy and chronic
pain, and prescribed medication in relation to these matters. He said he had
no thoughts of suicide or self-harm.
A cell sharing risk assessment (CSRA) was completed, and the man said he
would not share a cell with a prisoner from a minority ethnic group. He was
located on the fifth floor of B wing, which usually accommodates prisoners for
around one week from their arrival whilst an induction programme takes
place.
Two days after his arrival at Liverpool, the man saw a psychiatrist who
diagnosed alcohol dependency syndrome and recommended that he continue
the course of Librium. He noted that he did not suffer from depression or
psychosis.
On 14 August, the man moved to cell B4-26. This is on the fourth floor of B
wing, which usually accommodates remand and unsentenced prisoners. He
began sharing a cell with a prisoner around the same age. The next day, his
personal officer introduced herself to him and noted that he had “no problems
or concerns”.
The man’s prescription charts indicate that he did not take any medication
after 18 August, though he had been collecting it as scheduled until that point.
His reducing course of Librium was due to run until 20 August, and his
medications for epilepsy and pain relief were prescribed on an ongoing basis.
A court hearing was held at Crown Court on 21 August. The man did not
attend court, but took part in the proceedings via video link. His case was
adjourned until 16 October.
On 30 August, when the man had failed to collect his medication for 12 days,
a ‘refusal of treatment’ form was completed. This listed his ongoing
prescription medication and contained a short, pre-printed disclaimer
indicating that a member of the healthcare team had advised him to continue
taking it, but that he did not wish to do so. He signed the form and printed his
name.
The man was offered an appointment for a secondary health screening on 21
September, but he did not attend. A further court hearing was held on 16
October, with him again contributing via video link. His trial was scheduled to
start on 15 February 2010. On the same day as the court hearing, he was
sent an appointment letter, again inviting him to attend a secondary health
screening on 19 October 2009. However, he again chose not to attend.
Between August and October, there were no recorded staff concerns that the
man would kill or harm himself. He was described in his wing history record
as having no problems and, during interviews after his death, members of
staff described him as generally quiet but not withdrawn or vulnerable.
On 5 November, a Senior Officer (SO) received information from the prison’s
security department that, during a telephone call to his sister, the man had
said he was going to “end it”. The SO spoke to him in the wing office during
the same day, and was reassured that he did not mean what he had said
during the call. The man attempted to telephone his sister but he was not
able to reach her. He spoke to her from the wing office the following day in
the SO’s presence, and reassured her about his well-being. The SO thought
the situation had been resolved, and monitored him informally over the next
few days.
During interview with my investigator, several members of B wing staff
reported that the man began to seem increasingly tense and nervous in late
December 2009 and throughout January 2010. He made numerous
telephone calls to his solicitor and was frustrated by feelings that some of the
paperwork did not properly represent their discussions.
The man’s cellmate moved out of the shared cell on 29 January, having been
informed three days earlier of his daughter’s death. The move was not due to
any problems with the man, but instead because he thought he would be able
to cope better in a cell on his own after receiving such traumatic news. The
man remained in the same cell.
On the evening of 31 January, the man had separate, short conversations
with two members of staff, one around 5.00pm and the second around
8.00pm. There was no cause for concern. As he was not subject to any
special monitoring during the night, his cell was next checked during the
morning roll count (a process involving counting all the prisoners).
When the man’s cell was checked around 5.20am, he was found hanging
from a ligature which had been fashioned from a bed sheet and run over the
top of the toilet door. Several officers and two nurses arrived very quickly and
started cardio-pulmonary resuscitation (CPR). Despite continuous and
uninterrupted efforts until the paramedics arrived, he could not be
resuscitated. He was pronounced dead by a paramedic at 5.45am.
I have investigated issues around the immediate response, clinical care,
communication between departments, and post-incident care for staff. I make
two recommendations and endorse a further five recommendations from the
clinical reviewer.
THE INVESTIGATION PROCESS
1. One of my senior investigators opened the investigation on 1 February
2010 and visited HMP Liverpool on 4 February. He met the following
people:
(cid:127) the PPO’s liaison officer and the Safer Custody manager
(cid:127) the Head of Safer Custody
(cid:127) the Safer Custody administrative officer
(cid:127) the prison chaplain
(cid:127) the prison family liaison officer
(cid:127) the Chair of the Prison Officers’ Association
(cid:127) the coroner’s officer from Liverpool Coroner’s Office
2. The various people present at the meeting explained the background to
the man’s imprisonment and the circumstances of his death. Night
staffing was discussed in brief terms. The liaison officer explained that
there had been a single incident in November 2009 which had raised
some concern about the man’s well-being, but that at the time of his
death there had been no known issues around suicide or self-harm.
3. The liaison officer facilitated access to all of the records regarding the
man’s remand period in custody.
4. One of my family liaison officers (FLOs) having been unable to speak
with the man’s sister directly, wrote to her to explain the purpose of the
investigation and offer his family the opportunity to raise any questions
or concerns. The family did not raise any specific concerns to the FLO.
5. On 8 June 2010, the investigator met the man’s two sisters at the
Coroner’s Court. They asked why he was checked at 5.20am on 1
February 2010, and if this was in response to any specific concerns.
They also wondered why SO A did not take any formal action as a
result of his conversation with him on 5 November 2009. Finally, his
sisters were concerned that the prison’s healthcare department did not
appear to have his community medical notes, and that after he stopped
taking his medication and signed a disclaimer, there was no further
clinical intervention.
6. The issues that the man’s sisters have raised are covered in this
report, which I hope helps them better understand the events leading to
his death. The family received a copy of the draft report, however
raised no further questions in relation to the findings of the
investigation.
7. The investigator retuned to Liverpool in March 2010 with an Assistant
Ombudsman. They conducted recorded interviews with ten members
of staff. Transcripts of these interviews were produced and are
annexed to this report.
8. A prisoner who shared a cell with the man during much of his time at
Liverpool, was released before the investigator conducted interviews.
The investigator wrote to him at his release address but received no
reply.
9. The local Primary Care Trust (PCT) appointed a clinical reviewer to
conduct a review of the man’s clinical care whilst in custody. (The
purpose of a clinical review is to examine the medical care that a
prisoner received whilst in custody, which should be of an equivalent
standard to what might have been expected in the community.) She
consulted his medical records from his time at Liverpool and, with the
investigator, visited the prison on 18 March to talk to members of the
healthcare staff. Her findings are summarised in this report and the full
clinical review is included as an annex.
10. My investigator was informed by a Detective Sergeant (DS) of
Merseyside Police of an ongoing investigation concerning the man’s
solicitor. The DS said an allegation had been made that the man had
made a telephone call to a receptionist at his firm of solicitors, around
January 2010, and that during this call he threatened to kill himself. At
the time of writing this report, the police investigation was ongoing.
HMP LIVERPOOL
11. Liverpool is one of the largest prisons in the estate, with a maximum
operational capacity of 1359. It serves courts from the Merseyside
area, and holds remanded, unsentenced and convicted adult male
prisoners. There are eight residential units, including those for drug
support, vulnerable prisoners, detoxification, and resettlement. One of
the units holds people who are unsentenced or on remand, and it is
here that prisoners spend their first night and complete an induction
process to help familiarise them with the prison regime.
12. Healthcare services at Liverpool are provided by the local Primary Care
Trust (PCT). A purpose-built hospital unit, which opened in 2007,
allows healthcare staff to provide outpatient and inpatient facilities. A
doctor is on duty every day during normal working hours, and nursing
staff remain on duty throughout the night.
Performance
13. The Ministry of Justice produces quarterly performance figures for all
prisons in England and Wales. Every establishment is given a rating
between 1 and 4 based on 34 agreed performance indicators. The
most recent figures available at the time of writing are for quarter 3 of
2009-2010 (October, November and December 2009). For this period,
Liverpool received a rating of 2, indicating that the prison required
development to meet the agreed standards. This was a drop in
performance from the previous quarter, at which time the prison
received a rating of 3.
14. HM Chief Inspector of Prisons inspected Liverpool in September 2009.
Her report found that the support for people at risk of suicide or self-
harm was variable. The quality of education and employment was
good, though access to these activities was a problem for some
prisoners. She noted problems with violence and bullying, the
availability of drugs, and the reception and first night procedures.
Relationships between prisoners and staff were, however, generally
good.
Previous deaths at HMP Liverpool
15. The Ombudsman’s office has been responsible for investigating deaths
in custody since April 2004. Prior to the man’s death, 14 other
apparently self-inflicted deaths have been investigated. Three
occurred in 2004, five in 2005, four in 2006, and one in 2008. The
most recent death, before that of the man, was in February 2009.
16. The man was located on B wing, which usually accommodates remand
and unsentenced prisoners, at the time of his death. Before his death,
the last apparently self-inflicted deaths on B wing occurred in August
and November 2006.
17. Another prisoner died at Liverpool on 18 February 2010, just over two
weeks after the man’s death. Although he was a remand prisoner, he
was located on K wing (for vulnerable prisoners) rather than B wing. At
the time of writing, the investigation into this death is ongoing.
18. Aside from the method used (hanging by ligature is the most common
form of self-inflicted death in prisons) there are few similarities between
the man’s death and the deaths of other prisoners at Liverpool. The
man who took his life on B wing in November 2006 had been convicted
and sentenced. The man who took his life in August 2006 was a
remand prisoner like the other man, though the circumstances were
quite different. In that case, the prisoner had been at Liverpool for little
more than one month, and was identified from the outset as being a
risk to himself. The man had been at Liverpool for several months and
was not thought to be a risk of suicide or self-harm.
KEY FINDINGS
19. The man appeared at Magistrates’ Court on 8 August 2009 and was
remanded to HMP Liverpool.
20. An initial health screening was completed at 1.45pm by Staff Nurse A
at Liverpool. She noted that the man was slightly unkempt in
appearance but he had no concerns about his physical health. She
also recorded that he was drinking two to three litres of alcohol daily
(the type of alcohol was not specified at this point). She noted that he
had not harmed himself in the community or whilst in custody, though
this information would have been based primarily on his own account.
21. Staff Nurse A referred the man to the duty doctor, whom he saw at
2.00pm. The clinical record indicates that he saw Staff Nurse B.
However, in conversation with my investigator, Nurse B explained that
the man had actually seen a locum doctor who did not have any
access to System One (the computerised medical system used by
Liverpool), and so used her information to record the details of his
appointments. Thus, whilst the clinical record shows that he was seen
by Nurse B, he was in fact assessed by a locum doctor.
22. The doctor recorded that the man suffered from epilepsy and chronic
pain in his left knee, and had suffered a head injury in 2001. He noted
that the man had no thoughts of suicide or deliberate self-harm. The
doctor prescribed Phenytoin (to treat epilepsy) and Diclofenac (an anti-
inflammatory and analgesic drug). He also prescribed a 13-day course
of Chlordiazepoxide (commonly known as Librium) for alcohol
withdrawal, and referred him to the drug dependency unit (DDU). The
doctor did not mention the Librium prescription in the main clinical
record, but recorded it on the separate, handwritten prescription chart
along with the other medications.
23. The man saw an alcohol support worker with the DDU at 2.25pm. He
told him that, for the last six weeks, he had been drinking two to three
litres of cider daily, and had received Librium whilst in police custody.
24. A cell sharing risk assessment (CSRA) was completed upon the man’s
arrival. This is intended to identify any risks associated with prisoners
sharing a cell. Officer A, who completed the form, noted that he said
he would not share a cell with a prisoner from a minority ethnic group.
He also wrote that he had a previous conviction for a racially
aggravated offence, and so was not to share a cell with a prisoner from
a minority ethnic group. Officer A assessed him as a medium risk,
meaning that the situation would need to be reviewed regularly. A
separate section of the form covers health-related issues, though
Nurse A did not identify any concerns in this area.
25. Following these initial processes, the man was located on the fifth floor
of B wing, in cell B5-25. This floor is usually used to accommodate
prisoners for around one week from their arrival. During this time, an
induction process takes place to familiarise prisoners with various
aspects of the regime. Since he had served a number of previous
custodial sentences, some of them at Liverpool, it is likely that he
already had a reasonable understanding of prison life.
26. On 10 August at 9.50am, the man saw a psychiatrist. The psychiatrist
wrote in the clinical record that the man had alcohol dependency
syndrome, and recommended that he continue with his course of
Librium. He also mentioned that the man had epilepsy, but noted that
he did not suffer from depression or psychosis.
27. At 10.20am on the same day a general practitioner working at
Liverpool made a note in the clinical record of the man’s prescription
medication. In conversation with my investigator on 18 March 2010, he
explained that he had not seen the man at this time, and was merely
noting in the record the medicines that had been prescribed two days
earlier by the locum doctor. Although an appointment had been made
for the man to see him on 10 August 2009, the clinical record states
that he did not attend.
28. The man moved to B4 landing on 14 August. Whilst the fifth floor is
used for inductions, the fourth floor usually accommodates remand and
unsentenced prisoners. He was located in a shared cell, B4-26, with a
prisoner of a similar age. The following day, Officer B wrote in his wing
history record that she had introduced herself as his personal officer
and that he had “no problems or concerns”. A personal officer is a
named prison officer from the wing on which the prisoner is located,
and someone to whom the prisoner can direct concerns and queries.
Personal officers are also responsible for making regular notes in their
prisoners’ wing history records.
29. On 17 August, SO B conducted a cell sharing risk review. No issues
were raised further to those identified on 8 August, and the man
remained a medium risk.
30. The man’s prescription charts show that he did not take any medication
after 18 August. His reducing course of Librium was due to run until 20
August. Nurse C told the investigator that it is not particularly unusual
for prisoners to stop taking Librium before the end of the course,
because their alcohol withdrawal symptoms may have subsided.
However, the Phenytoin for epilepsy and the Diclofenac for pain relief
were supposed to continue on an ongoing basis. The man did not
have any of his medication in his own possession, and so was required
to collect it each day. His prescription chart shows that he last
collected his medication on 18 August.
31. A court hearing was held via video link on 21 August. This means that
the man did not leave the prison to appear in court, but he was able to
see the court proceedings on a video screen and to contribute as
required. Similarly, the people in the court would have been able to
see him on a screen. The hearing was at Crown Court, and the case
was adjourned until 16 October.
32. On 30 August, a ‘refusal of treatment’ form was completed regarding
the man’s medication. The form listed the medication offered
(Phenytoin and Diclofenac) and included the following pre-printed
statements:
“It has been explained to me by a member of the healthcare staff,
that it is advisable that I avail myself to this treatment.
“I don’t wish to avail myself to the treatment.”
33. Underneath these statements, the man signed the form and printed his
name. The remainder of the form, which provides space for the details
of the member of staff witnessing the prisoner’s signature, was not
completed.
34. Officer B wrote in the man’s wing history record on 30 August: “The
man has kept a very low profile since arriving on B wing. No problems
or concerns.” This was a sentiment echoed during interviews that the
investigator conducted with members of B wing staff. The officer said
the man was “a very quiet individual who was very polite to staff”. She
added that he did not associate very much with other prisoners, saying:
“He would stand outside his cell … and just watch the world go by,
and just made sure he had plenty of cups of tea and that was it
really, to be honest, and occasionally he’d come and speak to staff
and just have a general chit-chat about soaps [meaning the
television programmes] and that was it. He was very much a loner.”
35. Officer B said that although the man spent much of his time alone, he
did not seem particularly withdrawn, and she had no concerns around
self-harm or suicide.
36. During interview, Officer C recalled the man in a similar way. He said:
“He was a very, very quiet man on the landings. He would always
speak to you when he needed to speak to you and he wasn’t one of
them that would just stand there all day talking to you. If he needed
you or he needed to speak to you or needed your advice then he
would come and see you. But he wouldn’t be one of them that
would just stand there and just talk about the time of day or
anything like that. He was mostly very, very quiet I thought.”
37. Officer C also described the man as an “old timer”, someone who was
respectful towards members of staff and who had a good
understanding of the prison regime.
38. On 7 September, a further cell sharing risk review was carried out. He
remained a medium risk, and continued to share his cell.
39. An appointment slip was sent to the man on 18 September from the
healthcare unit, inviting him to attend a secondary health screening on
21 September. (A secondary health screening is similar to the initial
health screening completed when prisoners arrive at the prison, but
usually takes longer and is more detailed.) A note was made in his
clinical record that he did not attend for this appointment.
40. On 26 September, Officer B wrote in the man’s wing history record that
there were “no problems or concerns to report”. This is consistent with
the view expressed during interviews that he was polite and well-
mannered to members of staff, and that his behaviour did not cause
any concern or alarm.
41. The man’s risk in terms of cell sharing was reviewed again on 6
October. By this point, he had been sharing his cell with another
prisoner for almost two months. He remained a medium risk and
continued to share his cell. In terms of his relationship with his
cellmate, the officer (who was personal officer to both prisoners) said:
“I do know that when I spoke to both of them … individually … I’d
asked them if they were getting on fine and they’d both say yes,
fine. But there didn’t seem to be much communication between
them. They weren’t laughing and joking when you’d open the door.
They’d be both sat watching the telly, the man would be lying on the
bed and [his cellmate] would be sat by the table by the door. But
they never seemed to argue … there never seemed to be an
atmosphere but they didn’t seem to be the best of buddies.”
42. On 16 October, a further court hearing was held at Crown Court, again
with the man contributing via video link. His case was adjourned, with
a trial scheduled to commence on 15 February 2010. Also on 16
October, an appointment slip was sent from the healthcare unit, giving
him another opportunity to attend a secondary health screening on 19
October. However, he did not attend this appointment either.
43. Officer B noted in the man’s wing history record on 4 November that he
had “gone to labour as and when required”. During interview, she
confirmed that this could refer to either work or education, and that he
had been attending education classes.
44. On 5 November, SO A wrote in the B wing observation book that he
received information from the security department that, during a
telephone call to his sister, the man had said he was going to “end it”.
The SO wrote that he interviewed him, who assured him that he had
made an “off the cuff” remark and would call his sister to explain that
he was fine.
45. During interview with my investigator, SO A explained that his
understanding of the situation was that the man’s sister had telephoned
the prison after he made the comment during a call. She had been
transferred to the security department and had outlined her concerns,
and the security department had alerted B wing to the situation. The
SO said he then asked for the man to be brought to the wing office,
and they had a conversation about the concerns. Initially, the SO
approached this in a general way and asked if there was any reason
for people to be worried about his well-being, but he said this was not
successful. Eventually, he had to tell the man that his sister had
telephoned the prison. It was at this point that he reassured the SO of
his well-being, and said he would call his sister to clarify the situation.
46. The SO suggested that the man make the telephone call from the wing
office and, although this was attempted, there was no reply. Another
call was placed later the same evening, but again his sister did not
reply. The SO said the man managed to speak to his sister from the
wing office the next morning, whilst he was present in the room. He
said that during his conversations with him he did not have any
concerns about his well-being. He added that he wanted to ensure he
spoke to his sister to reassure her, but he also wanted to see and hear
how he presented when speaking to her.
47. My investigator asked SO A if he would have taken any further action if
he thought the man was at risk to himself. He said he would not have
hesitated to open an Assessment, Care and Custody and Teamwork
(ACCT) document in these circumstances. (ACCT documents are
designed to help manage and support prisoners who are at risk of self-
harm or suicide.) He thought the matter was resolved and that the
opening of such a document was not necessary. He told my
investigator that he informally monitored the man for a few days
afterwards, and was satisfied that the situation had been managed
appropriately.
48. On 21 November, Officer B wrote in the man’s wing history record that
he was causing no problems or concerns. On 27 November, an
appointment slip was sent to him from the healthcare unit, inviting him
to attend for a flu injection on 30 November. He did not attend the
appointment. A further appointment slip was issued on 4 December for
an appointment on 7 December. This was another opportunity for the
injection. There is nothing in the clinical record to show whether or not
he attended this appointment.
49. Nothing of significance was reported until 13 January 2010, when the
man was dismissed from his education classes. This followed a
security information report (SIR) on the same morning which stated
that he had used a computer in one of the classrooms for
“inappropriate literary composition”. The document appeared to be a
personal account relating to the alleged offences with which he had
been charged. A note was made in his wing history record by an
officer which simply stated: “Sacked education.”
50. Three days later, Officer B wrote the following in the man’s wing history
record: “The man has got an ongoing problem with getting in contact
with his brief [meaning his solicitor]. He is attending education on a
daily basis.” It appears that at this point, she was not aware that he
was no longer attending education classes, having been dismissed.
51. The issue of the man having problems contacting his solicitor was also
mentioned by members of staff during their interviews with my
investigator. Officer B said that shortly after Christmas 2009, the man
became more preoccupied with his forthcoming trial and seemed tense
and nervous about it. He also made numerous telephone calls to his
solicitor and was frustrated by some of the paperwork which he felt did
not represent what he had told her over the telephone. Officer C
recalled that the man had problems reaching his solicitor by telephone,
and said that they would often leave his cell door open for periods of
time to allow him to use the telephone.
52. The man’s cellmate moved out of B4-26 and to another cell on 29
January 2010. Three days earlier, the cellmate had been informed of
the death of a close family member, and felt that he would cope better
in a cell on his own. The man remained in the same cell as the sole
occupant.
53. On 30 January at 10.57am, Officer B wrote the following in the man’s
wing history record: “The man has been very stressed of late due to his
trial starting soon. He has attended work when required.” She wrote a
further entry at 11.01am, stating: “The last entry was inputted by
mistake. He has been sacked from education.”
54. Officer B mentioned during interview that the man remained tense
about his trial at this point and dissatisfied with the situation regarding
his solicitor.
31 January – 1 February
55. On 31 January, Officer D was working on B wing. During interview with
my investigator, he remembered having a brief conversation with the
man before locking his cell door around 5.00pm. The conversation
was not about anything in particular; the officer recalled that he was
checking that the man was generally okay, as he would with any other
prisoner, before locking his cell for the night. At that time, he had no
concerns about his well-being, and did not notice anything unusual
about his presentation or demeanour.
56. During the night, each of Liverpool’s residential wings is staffed by
either a prison officer or an officer of operational support grade (OSG).
On the night of 31 January, an OSG began his shift on B wing at
8.00pm. He explained during his interview with my investigator that
one of his first duties was to complete a roll check – essentially, to
count the prisoners on the wing and ensure that the number was
consistent with the previous count.
57. The OSG recalled that upon arriving at cell B4-26 he realised that it
was a double cell but that there was only a single occupant: the man.
He remembered having a brief conversation with him, asking him if he
was alone in the cell and whether he was okay to be alone. He
answered, “Yes I am, thank you.” Although he was not able to recall
the specific time of this exchange, the OSG believed it took place a few
minutes after 8.00pm.
58. During his interview, the OSG explained that part of his job is to patrol
the wing overnight, paying particular attention to prisoners who have
been identified at risk of self-harm or suicide, those known to have
attempted escape, and those in the highest security category. As the
man was not in any of these categories, the OSG had no cause to
specifically check his cell until the time of the next full roll check,
around 5.00am.
59. The OSG told my investigator that he began the roll check shortly after
5.00am on 1 February. The roll check involves counting every prisoner
and confirming that they are present in the cell. He said that, in order
to do this, it is necessary to switch on the cell’s interior light using a
switch located outside the cell, and look into the cell through the
observation panel. He recalled arriving at the man’s cell at 5.18am
and, upon switching on the light, saw him hanging from the toilet door,
which was opened out into the cell.
60. The OSG used his radio to contact the night manager, SO C, who had
the radio call sign ‘Oscar’. (All members of staff in the prison with a
radio have a unique call sign depending on their role, and the night
manager is known as Oscar.) He said over the radio that he needed
Oscar’s help on B wing as soon as possible, but did not elaborate on
the nature of the situation. He explained that during the night, the
radios are switched to a ‘talk-through’ mode which enables all
members of staff with a radio to hear all radio communications,
whether specifically intended for them or not.
61. Officer E was working on A wing, which is adjacent to B wing. Upon
hearing the OSG’s radio message, which he recalled as happening
around 5.20am, he made his way to B wing. He initially thought the
situation was not urgent, but the wings are close together, and so he
reached B4 landing in under one minute. He asked the OSG what had
happened, and was told that a prisoner was hanging in his cell. He
looked into the cell himself, and used his own radio to make it clear
exactly what had happened. He recalled that by this point, SO C had
arrived on B wing and was climbing the stairs to join them.
62. SO C and the Acting SO were in the central office at the time of the
initial radio message. Nurse C was in the central surgery, located
close by. SO C said that upon hearing the radio message, he asked
the OSG what was wrong, and received a message that he was
required on B wing immediately. He said that, although the actual
nature of the situation had not been made clear, he assumed it would
be serious. SO C, the Acting SO and Nurse C ran to B wing. Whilst en
route, the SO radioed Officer F, who was located on B1 landing, to go
to B4. He was also aware that Nurse D, a registered mental health
nurse, located in the healthcare unit radioed Nurse C to ask if her
assistance was required. The SO estimated that he, the Acting SO
and Nurse C arrived at B wing within a minute.
63. SO C recalled that as he was climbing the stairs to B4 landing, Officer
E made him aware that the situation involved a prisoner found hanging
in his cell. As he reached the landing, he was able to see into the cell
through the observation panel. He immediately opened the cell door
and radioed the prison’s control room to request an ambulance. He
then used his anti-ligature knife (a piece of equipment carried by
operational staff and often referred to as a ‘fish knife’ due to its shape)
to cut the ligature. As he did so, Officer E took the man’s weight. It
appeared that the ligature had been made from a torn bed sheet and
had tied to a pipe near the floor of the cell and run over the top of the
toilet door.
64. The man was laid on his back on the floor of the cell, with his head
nearest to the door. Nurse C asked for a bag containing the
emergency medical equipment. The nearest of these was located on A
wing, and the SO asked the Acting SO to retrieve it. The nurse said
the man showed no signs of life, and he began chest compressions
whilst waiting for the emergency bag to arrive. The Acting SO said it
took him only around 25 seconds to leave the landing, retrieve the bag
and return, and the nurse recalled it arriving very quickly. At the same
time, Nurse D also arrived.
65. Nurse D attached an automated external defibrillator (AED) to the man.
(This is a device that monitors the heart rhythm of a patient and
administers a shock if appropriate.) Both nurses recalled that the AED
did not detect a heart rhythm and advised that chest compressions
should continue. Nurse D attempted to use an ambu-bag (a piece of
medical equipment involving a tube that can be inserted into a patient’s
airway) but said this proved impossible because the man’s airway was
obstructed. Both nurses and Officer E continued with chest
compressions until the paramedics arrived.
66. Officer F was instructed to keep a log of events. He noted that
members of staff were initially called to the man’s cell at 5.27am,
although this would appear to be an estimate as he had not been
asked to start a log at the time of the initial radio message. His log
notes that the ambulance was called at 5.29am and arrived at 5.37am.
67. Both nurses recalled that when the paramedics arrived they attached
their own equipment to look for any signs of life. Officer F’s log records
that they retired and pronounced the man dead at 5.45am.
68. Police officers arrived at the prison at 6.15am, and at 6.35am four
officers went into the cell with SO C. The SO was already aware of an
envelope on the top bunk bed, but was conscious of the need to
maintain the scene for the police. He recalled that one of the police
officers opened the envelope, which contained a letter. The officer
made the SO aware of its content, but the letter itself was taken by the
police as evidence.
69. The investigator obtained a copy of the letter from the police. It was
four pages long, addressed to the man’s sister, and dated 31 January
2010. He outlined his version of events regarding the alleged offences,
and wrote about problems he was experiencing with his solicitor. In
particular, he thought his solicitor was misrepresenting him in the
statements that she was writing. He then went on to write about his
possible sentence and how he felt he would not cope well in prison for
a long period of time. At the end of the letter, he wrote that he did not
have to time to finish it because he needed to post it, and signed his
name. Underneath, he wrote: “Tell my mum I love her and I’m sorry for
what I’ve done but there is no way out.”
70. A meeting known as a hot debrief took place at 7.35am. It was chaired
by the Head of Operations and the duty governor. The members of
staff who had been directly involved attended the meeting. Notes from
the hot debrief show that members of staff were told that the care team
would be available to speak to them. The immediate response after
the alarm was raised was discussed. The general feeling was that
everyone concerned had acted quickly and efficiently. The meeting
was concluded at 8.05am.
71. The Head of Safer Custody and the prison chaplain left the prison at
8.30am to inform the man’s family of his death. There was a delay
because his nominated next of kin, his mother, was not at home and it
eventually transpired that she was in hospital. They were able to
inform his sister of his death shortly after 11.00am.
ISSUES
Immediate response
72. It would appear that, following the OSG’s discovery of the man during
the roll check, the response was swift. Officer E said he arrived at B4
landing less than a minute after the initial radio message. SO C said
that he, along with the Acting SO and Nurse C, also arrived within a
minute.
73. Nevertheless, the initial radio message lacked clarity. The SO, an
experienced night manager, said he assumed that such a radio
message at that time in the morning would be about something urgent,
and he ran from the central office to B wing. This was an implicit
understanding, though, rather than a direct response to a clear
message. Conversely, Officer E did not initially think the situation was
urgent, and although he immediately made his way to B wing, he might
have attempted to get there more quickly had he realised the nature of
the situation.
74. Liverpool uses specific radio codes so that emergency situations can
be identified as such by all members of staff. A ‘code red’ message
over the radio indicates severe loss of blood, whilst a ‘code blue’
means that someone is suffering from breathing difficulties or requires
resuscitation. Although the OSG used his radio to ask for assistance,
he did not use the recognised radio code to alert other members of
staff to the nature of the situation.
75. In this instance, the radio message did not impede the response and
there was no delay. However, the benefit of a clear, unambiguous
radio message for such a situation is obvious.
Members of staff should use the established radio codes to
inform others of the nature of medical emergencies.
Clinical issues
76. The man did not have a great deal of contact with the healthcare unit at
the prison. Routine assessments were made by several members of
staff upon his arrival on 8 August 2009. Medication for epilepsy, pain
relief, and alcohol withdrawal was prescribed. He was seen by a
psychiatrist on 10 August and, other than when collecting his
medication he did not have any further contact with the healthcare unit.
77. Despite this limited contact, the clinical record is unnecessarily
confusing. On 8 August, the man was seen by a doctor but the entry is
recorded in the name of a staff nurse. There is nothing within the entry
to suggest that it was written by someone else, and this only became
clear after conversation with the nurse whose name was used. This is
not good practice. The clinical record should accurately reflect
appointments with the patient and provide a clear audit trail. It is also
unacceptable for members of staff to make entries in the computerised
record under another person’s details. This is a practice which is
confusing, unclear and potentially dangerous. The clinical reviewer,
who was appointed by the local Primary Care Trust (PCT) to examine
the clinical issues, agreed that it was “very difficult to identify who had
seen the man and for what reason. It was also difficult to ascertain who
had prescribed the medication and when”.
78. The man was prescribed medication for epilepsy and pain relief on an
ongoing basis. However, he only took this until 18 August. A form
indicating refusal of treatment was not completed until 30 August,
some 12 days later. The form is handwritten and the spaces for the
member of staff to fill in their details are blank. Since there is no
corresponding entry in the computerised clinical record, it is impossible
to identify who completed this form with him, and what was said to him
at the time.
79. It is, of course, entirely the choice of individual prisoners as to whether
they take medication which is recommended and prescribed.
However, as prisoners are quite literally a captive audience, 12 days
seems a long time to wait before a refusal of treatment form is
completed. There is no evidence of what, if anything, was done in the
interim, particularly considering that the man was taking medication for
epilepsy and to stop would increase the risk of fits.
80. The clinical reviewer also found that the procedures for following up
missed appointments were unclear, as were the follow-up procedures
for patients prescribed medication for substance misuse.
81. The man’s family asked whether it is usual practice for the prison to
obtain community medical records for prisoners. The investigator
spoke to the clinical Head of Healthcare at Liverpool about this issue.
She told him that it was not standard practice to request medical
records for all prisoners, but that this was done as and when required
based on their clinical needs. She went on to say that most such
cases involved very complex mental health needs.
82. I endorse the following recommendations made by the clinical reviewer
in relation to clinical care:
The head of healthcare should ensure that record keeping is
improved, making it clear who has made the clinical entry.
Clinical staff should ensure that all consultations and discussions
with patients are recorded.
The head of healthcare should consider changes to the policy for
reviewing patients prescribed medication for alcohol misuse.
The head of healthcare should review the policy for follow-up of
patients who do not attend for secondary health screening.
The head of healthcare should review the policy for the
management and follow-up of patients who refuse prescribed
medication.
Communication
83. On 5 November 2009, some three months before the man took his life,
SO A addressed the issue of him making comments during a telephone
call which gave his sister cause for concern. The issue itself appears
to have been dealt with well. The SO spoke to him, witnessed him
speaking to his sister over the telephone, and monitored him informally
for a few days afterwards. As an experienced officer and someone
very familiar with the ACCT process, the SO felt that such a formalised
arrangement was not necessary. There is no reason to believe that
this was anything other than an appropriate decision.
84. SO A recorded the concerns about the man and his actions in the B
wing observation book. This is a document that contains a record of all
noteworthy occurrences on the wing. However, a note was not made
in the man’s own electronic wing history record. This would have been
a useful and easily accessible record should there have been any
further related incidents attended to by a different member of staff.
There is nothing to suggest that the lack of such an entry adversely
affected the outcome, but it would be sensible, good practice to ensure
that such events are logged in the wing history record.
The Governor should remind staff that relevant information about
prisoners should be recorded in the wing history record
85. Merely recording information in the wing history record does not
compel staff to readily access it. On 13 January 2010, the man was
dismissed from education classes and an entry (albeit very brief) was
made in his wing history record. It appears, however, that Officer B did
not notice that this information had been entered. On two subsequent
occasions, she wrote that he was attending education as required.
Whilst I do not make a recommendation, the Governor should remind
all staff of the importance of the wing history record as a source of
valuable information about prisoners.
Post-incident care for staff
86. The minutes from the hot debrief meeting on 1 February indicate that
members of staff in attendance were made aware of the support that
they could expect to receive from the prison’s care team.
87. The members of staff who work overnight generally work for seven
nights in a row. This is followed by seven rest days. When the
overnight staff finished their shifts early on 1 February, they would not
return to work for an entire week. During his interview with my
investigator, SO C said he telephoned a number of staff members at
home to check on their well-being, though he himself was at home at
the time, and the calls were not made in an official capacity. This was
commendable behaviour on the part of the SO, who was keen to
ensure the well-being of his colleagues. However, being the night
manager directly involved in the immediate response to the man’s
death, the responsibility of checking on his colleagues’ welfare should
not have been left to him alone. During interview, he said that in the
week that followed the death, nobody else from the prison contacted
the night staff at home.
88. It would appear that whilst the care team is available for support, the
onus is on individual staff members to make contact. In situations such
as this, particularly when members of staff are not in the prison for
several days afterwards, it might be useful for someone from the care
team to make the initial contact. I do not make a formal
recommendation in this area, though I believe it is worth consideration.
CONCLUSION
89. The man had served a number of previous prison sentences when he
was remanded into Liverpool on 8 August 2009. He was familiar with
the prison and some of the members of staff.
90. Routine medical assessments were carried out and the man was
prescribed medication for alcohol withdrawal, epilepsy and pain relief.
He was not thought to be at risk of harming himself. He stopped taking
his medication on 18 August and later signed a form to say he did not
wish to continue with the treatment.
91. The man was described by wing staff as quiet, and someone who
preferred to spend much of his time alone. However, he was polite and
respectful to staff, did not cause any problems, and was not thought to
be at risk of harming himself.
92. On 5 November, SO A received information that the man had talked
about taking his life during a telephone call to his sister. After speaking
to him and asking him to call his sister, he thought the situation was
resolved.
93. Nearly three months later, at 5.20am in February 2010, the man was
found hanging in his cell. Members of staff responded quickly and
although resuscitation was attempted, he could not be saved.
94. My recommendations relate to radio call signs and the proper recording
of information. I also endorse recommendations from the clinical
review.
RECOMMENDATIONS
1. Members of staff should use the established radio codes to inform
others of the nature of medical emergencies.
The recommendation was accepted. The Governor will issue a notice
to staff highlighting the issue, and it will also be included in the
induction training for staff members who carry radios.
2. The Governor should remind staff that relevant information about
prisoners should be recorded in the wing history record.
The recommendation was accepted. The Governor will issue a notice
to staff. All entries will be recorded on the P-NOMIS computer system
and subject to quality checks by managers.
3. The head of healthcare should ensure that record keeping is improved,
making it clear who has made the clinical entry.
The recommendation was accepted. All entries on the medical
computer system will include the date, time and the identity of the
author. This will be subject to regular management checks.
4. Clinical staff should ensure that all consultations and discussions with
patients are recorded.
The recommendation was accepted. All consultations with patients will
be recorded on the medical computer system and this will be subject to
regular management checks.
5. The head of healthcare should consider changes to the policy for
reviewing patients prescribed medication for alcohol misuse.
The recommendation was accepted. A ‘whole systems alcohol service’
is under development. A project lead has been appointed.
6. The head of healthcare should review the policy for follow-up of
patients who do not attend for secondary health screening.
The recommendation was accepted. Nurses will hand deliver
appointments to patients. They will also speak to patients who do not
attend and either re-list them or document the reasons for non-
attendance.
7. The head of healthcare should review the policy for the management
and follow-up of patients who refuse prescribed medication.
The recommendation was accepted. All refusals of medication will be
discussed with the patient, a disclaimer will be signed, and this will be
documented on the clinical record.