Individual at Cardiff

Investigation into the death of a man whilst in the custody
of HMP Cardiff in November 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
The man was found at 6.55am in his cell at HMP Cardiff, having cut himself and bled
to death during the early hours. He was 40 years old. I offer my sincere sympathy
and condolences to those touched by his death.
The investigation was carried out on my behalf by my colleague. A clinical review of
the man’s healthcare was undertaken on behalf of the Health Inspectorate Wales. I
am grateful for her review. I would also like to thank the Governor of Cardiff at the
time of the man’s death and her staff for their co-operation and assistance.
Particular thanks go to principal officer and his team for their help throughout the
investigation.
The man experienced several problems prior to coming into custody. He suffered
depression, physical ailments, relationship breakdown and a suicide attempt in the
years before he was arrested on a charge of arson. He was given a cell in the
healthcare department as he needed a wheelchair and had other medical issues.
Once in healthcare, staff thought that he settled well although he confessed to staff
that he had no-one outside prison who could bring him in personal items that he
wanted.
The death of a friend in the healthcare department upset him and he did not want to
move to a residential prison wing. This attitude took the form of several breaches of
discipline. Despite this, he did move to F Wing where staff were of the view that he
was coping well. However, he took his life only a few weeks later. The note that he
left behind seems to suggest he was suffering greatly from depression and
loneliness. It is deeply unfortunate that he felt unable to share the depth of his
unhappiness with staff.
The man met many of the criteria for those who may be at risk of harming
themselves. However, I can understand why none of the staff took the step to open
formal suicide and self-harming monitoring procedures. He did not unburden himself
to them and seemed more preoccupied with coping with his physical ailments and
medication. I believe that a revised system of assessing prisoners upon their arrival
into Cardiff could help identify prisoners who may at risk in the future.
This case clearly highlights the need for a custodial system that has the time and
resources to look at a prisoner holistically. When one stands back to look at his
situation it becomes apparent that his life was on a decline and prison may have
been too much for him to cope with. Considering his life in its entirety might have
provided the support he clearly needed. I am satisfied that the man gave no
indication that he was unduly distressed. Unfortunately staff did not recognise that
he was especially at risk or that leaving healthcare had reduced the level of support.
My only recommendations concern record keeping and the completion of
documentation.
The version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman September 2010
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CONTENTS
Summary
The investigation process
The man
HMP Cardiff
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was born on 15 December 1968. He developed pain in his legs which
resulted in him losing his job and having to use a wheelchair. He entered HMP
Cardiff on 24 September 2009 having been charged with arson and recklessly
endangering lives. During his initial healthscreen interview, he explained that he
suffered from depression, had attempted suicide two years earlier and required a
different wheelchair to the one he had in prison. He denied any thoughts of harming
himself and was allocated a cell in the healthcare centre.
The man began a hunger strike on 26 September as a protest against what he
deemed to be his unjust imprisonment. This lasted until 7 October when he ended it.
He told staff that his actions were a form of protest rather than a means of harming
himself. Following his hunger strike, he settled into life in the healthcare centre and
formed friendships with some of the other prisoners.
Staff began to plan for him to be moved to a residential prison wing as they judged
that the man did not need to be in the healthcare centre for medical reasons. He
was adamant that he did not want to leave healthcare and engaged in several
breaches of discipline in an attempt to remain there. At this time, he also became
distressed when a friend died in the centre.
Despite the man’s efforts to remain in the healthcare centre, he was moved to a cell
on F Wing, following a short stay on A Wing. Once he went to F Wing there was
very little recorded about his life in the prison files. A prisoner told the investigator
that the man was being bullied on F Wing. The investigator was unable to find any
evidence that it happened or that prison staff were aware of it. The staff who the
investigator spoke to believed that the man was getting on well on F Wing and had
no concerns for his welfare.
Unfortunately, the man was clearly struggling more than anyone knew and
apparently took his life during the early morning of 16 November. He was found
during the morning roll check. Staff did not attempt to resuscitate him because he
had already passed away. The Governor visited the man’s wife to break the news to
her. This report contains three recommendations concerning record keeping and
completing documentation.
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THE INVESTIGATION PROCESS
1. The investigation was carried out by my colleague. My colleague visited HMP
Cardiff the day after the man’s death. He viewed the man’s cell and the
documents concerning him. Notices were issued to prisoners and staff to
alert them to the investigation. No-one came forward in response to the
notices. The Independent Monitoring Board and Prisons Officers Association
were contacted to make them aware of the investigation.
2. My colleague asked the Healthcare Inspectorate Wales to review the clinical
care received by the man. A clinical reviewer was commissioned to
undertake this review. The review took longer than expected which has
resulted in the delay of the publication of this report.
3. The Ombudsman’s senior family liaison officer wrote to the man’s wife and
parents to provide them with information regarding the investigation. They did
not raise any issues. I hope that this report offers greater insight of the man’s
time in prison.
4. My investigator travelled to Cardiff on 3 December to interview prison and
healthcare staff, and a prisoner. The clinical reviewer accompanied him and
was provided with the transcripts of the interviews. They returned to Cardiff
on 12 January and 18 February 2010 to conduct further interviews.
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The man
5. The man was born on 15 December 1968, and worked as a mechanic in the
later 1990s. He developed pain in his legs, which developed to the extent that
he could no longer walk. He had a spinal cord stimulator implanted to help
cope with the pain. (This is a small machine located in the body that is used
to send electric pulses to the spinal cord to control chronic pain.) He wore a
hearing aid as he suffered from progressive hearing loss in the right ear. He
was able to lip read.
6. Having left his job due to his disability, he took up wheelchair tennis and also
began coaching tennis. He suffered from depression and was prescribed
anti-depressant medication for over ten years. His relationship with the
mother of his youngest child had also recently ended.
7. He told staff that he had taken an overdose of paracetamol two years before
he came into prison. His alleged offence was arson and recklessly
endangering lives. He was denied bail and this was his first time in custody.
8. Despite some breaches of discipline, he generally got on well with staff at
Cardiff and several commented to the investigator how polite and respectful
he was in their conversations with him. The reverend remembered that the
man used to read a lot in his cell.
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HMP CARDIFF
9. HMP Cardiff is a category B local and training prison. (As a local prison,
Cardiff holds adult male prisoners received from the courts of South East
Wales.) Cardiff has an in-patient healthcare unit with room for 22 prisoners.
The clinical review includes the following summary of the healthcare facilities
available:
“The new Healthcare Centre at HMP Cardiff provides 24 hour primary
care and has 22 in-patient beds. All cells in the centre have been
designed to the “safer design” requirements. Two cells are gated and
have cameras in situ while two further cells have cameras in situ but
are not gated. [Gated cells allow staff to observe the prisoner at all
times.] Clinical care is provided by doctors and nurses employed by
the Prison Service. The team comprises two general practitioners
(supported by locums from a local general practice), a senior nurse,
practice manager, four supervisory grade nurse/senior healthcare
officers and 26 registered nurses. There is one full time and one part
time doctor who between them provide 13 sessions each week
including Saturday morning. Out of hours doctor cover is provided by a
local surgery.”
Incentives and earned privileges scheme
10. The incentives and earned privileges (IEP) scheme is a means of monitoring
prisoners’ behaviour and rewarding good behaviour and punishing poor
behaviour. Prison Service Order (PSO 4000) describes it as follows:
“The IEP scheme complements the discipline system by rewarding
good behaviour. In addition to any local aims, it is intended to
encourage prisoners and YOs [young offenders] to behave responsibly,
to participate in constructive activity, and to progress through the
system. This will foster a more disciplined and controlled, and
therefore safer environment for prisoners and staff. It should also
contribute to the reduction of re-offending by encouraging prisoners to
lead law-abiding, productive and healthy lives.”
11. Within the local system prisoners are able to move up a level (basic, standard
or enhanced) and earn various privileges. Poor behaviour can result in
moving down a level or losing privileges. Privileges include association time
and extra visits.
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Adjudications
12. Adjudications are described in the following way in Prison Service Order
(PSO) 2000 (Adjudications):
“An adjudication has two purposes:
(cid:127) To help maintain order, control, discipline and a safe
environment by investigating offences and punishing those
responsible;
(cid:127) To ensure that the use of authority in the establishment is lawful,
reasonable and fair.
“The role of the adjudicator is to inquire into a report of alleged events
and to decide whether an offence under Prison Rule 51 or YOI Rule 55
has been established beyond reasonable doubt. The adjudicator must
investigate the charge, being prepared to question, in a spirit of
impartial inquiry, the accused, the reporting officer and any witnesses.”
Assessment, Care in Custody and Teamwork (ACCT)
13. Assessment, Care in Custody and Teamwork (ACCT) is a care planning tool
used by the Prison Service to help support and monitor those prisoners
identified as being at risk of suicide or self harm. The ACCT process
encourages staff to work together to provide individual care to prisoners in
distress and help to diffuse circumstances where self harm or suicide may
occur.
Control and restraint
14. Staff are authorised, where necessary, to use control and restraint techniques
which involve the use of reasonable force.
Sealed key pouch
15. Officers do not carry keys during the night. If they need to enter a cell, they
must break a sealed key pouch to remove the key.
Independent Monitoring Board
16. Each prison has an Independent Monitoring Board (IMB) made up of
members of the community. The Board’s role is to ensure that the prison is
properly run and that prisoners are treated decently. Each Board produces an
annual report for the Secretary of State. The most recent report from the
Cardiff IMB covers the period 1 September 2007 to 31 August 2008. The
report stated that: “HMP Cardiff is a well-run establishment with good
relationships between staff and prisoners.”
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Her Majesty’s Chief Inspector of Prisons
17. HM Chief Inspector of Prisons conducted an announced inspection from 7 to
11 January 2008. The introduction to the report said: “Cardiff was essentially
a safe prison, where prisoners were much more likely to report feeling safe
than at other local prisons. This relied considerably on good relationships
between staff and prisoners.” Healthcare services were described as good,
and “Self-harm and suicide prevention was supported by a comprehensive set
of policy, procedural and guidance documents.”
Previous deaths at Cardiff
18. Cardiff experienced three self-inflicted deaths in 2009, in addition to the death
of the man. Two of the deaths were caused by hanging, and one by an
overdose of medication. None of these prisoners were subject to ACCT
monitoring procedures at the time of their deaths and, in two of the cases, the
deaths came as a great shock – as did the man’s.
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KEY FINDINGS
19. The man was arrested on 22 September 2009 on a charge of committing
arson recklessly and endangering lives. He was remanded into custody on 24
September and sent to HMP Cardiff. The prisoner escort record (PER) that
accompanied him to prison listed no concerns, although it contained notes
regarding his use of crutches and history of depression.
20. The initial reception healthscreen was undertaken. The initial impression was
of a well-groomed and fit man. He was able to stand for short periods and did
so for the height measurement. The nurse who did the initial reception
healthscreen told my investigator that the man was very specific about his
medical problems. He said that his wheelchair was incorrect and he did not
have the remote control for his spinal cord stimulator. (This is a small
machine located in the body that is used to send electric pulses to the spinal
cord to control chronic pain.) The nurse said that she asked him if he had
anyone who could bring them in for him, but he told her that he had no friends
or family.
21. The man told the nurse that he was a social drinker but did not have any
substance misuse issues. He said that he had been taking medication for
depression for over ten years and had made a suicide attempt two years
previously. However, he also said that he did not currently have thoughts of
harming himself. She said to my colleague that he could not understand why
he had not been granted bail.
22. The mental health section of the healthscreen was not fully completed. There
was no information provided on the man’s experience of psychiatric care, or
how the man appeared to the nurse. The nurse told the investigator that the
response to the questions should be read as ‘no’ if she had not marked either
answer.
23. The nurse recommended that the man be initially accommodated in the
healthcare department as she deemed him to be vulnerable. When
questioned by the investigator, she confirmed that she did not mean with
regard to harming himself but because it was his first time in prison and he
had certain medical conditions. She did not consider it necessary to begin the
Assessment, Care in Custody and Treatment (ACCT) procedures.
24. The cell sharing risk assessment was undertaken. This assessment contains
a series of questions which are put to the prisoner. One refers to the offence
and asks if the prisoner is accusing of committing one of a number offences,
including arson. It appears that the man did not admit that he was charged
with arson, as it is marked ‘no’ with a reference to the source of this
information being ‘I’ (inmate).
25. He said that he wanted a single cell due to his medical condition. He was
assessed as being at low risk of attacking a cellmate, but was accommodated
in a single cell in the healthcare centre. The cell he moved to was a ‘camera
cell’. (A ‘camera cell’ contains a video camera which constantly records what
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is happening in the cell.) This was apparently because staff were initially
unsure how mobile the man was.
26. The man told staff on 26 September that he had begun a hunger strike in
protest at what he believed to be his unjust incarceration. Healthcare
Assistant (HCA) told the investigator that the man was clear that his action
was a protest, rather than a form of harming himself. She said:
“ … he was quite adamant on the point, it wasn’t because he wanted to
hurt himself, he felt he shouldn’t be in prison and he felt that it was his
first offence and he should have been given bail. And it was a way of
drawing attention to the plight that he was in.”
27. Staff moved the man to a different cell on 27 September as they judged him to
be mobile enough for a regular healthcare cell. He signed a food refusal
advance directive on 29 September. The directive explained that it was his
decision to refuse food and he was aware of the potential consequences. The
prison began a monitoring document to check his well-being while he
continued to refuse to eat. The prison doctor visited the man on 5 October as
required by the monitoring document. He told her that he was refusing to eat
in protest. She confirmed that he was still taking fluids and medication. (His
medication was for the pain he experienced in his legs.)
28. The man ended his hunger strike on 7 October. The HCA noted that, on the
day of ending his hunger strike, the man specifically denied having any
thoughts of harming himself. The HCA said that he thought that the hunger
strike was having no effect:
“He felt that it was pointless, that no one had taken an interest in his
hunger strike and no one really beyond the prison knew anything about
it. And I think he just felt he was hurting himself and he gave up with
it.”
29. The prison doctor saw the man on 7 and 14 October during her routine ward
rounds. She told the investigator that he was always polite when she spoke
to him. The clinical reviewer recorded that during this time the man:
“ engaged in the routines of the healthcare unit, he interacted with his
peers and staff, attended to his hygiene needs and mobilised himself
using his wheelchair and crutches.”
30. On 9 October, the disability liaison officer undertook a disability questionnaire
with the man. He told her about his leg injuries and that his hearing was
impaired. He said that he could not always hear people if they spoke to him
through the cell door, and his life would be improved if he could understand
people better. The HCA told the investigator that the man was a good lip-
reader, but found it more difficult to understand people if he could not see
them properly.
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31. The man told the reverend that he needed a different wheelchair and the
remote control to his spinal cord stimulator, both of which were at his home.
The reverend told my colleague that she asked the man if anyone could bring
the items in for him but he told her that he did not have anyone who could do
this as he had alienated his family. However she said that she believed that
the healthcare department did not, at that time, view the items as necessary
and so she offered to collect them for the man. She received permission from
the prison to undertake this task but was unable to collect the items
immediately because the man’s home was sealed. (Unfortunately, she was
unable to collect these items for the man before his death.)
32. It was decided that the man would be able to cope on a normal wing and no
longer needed daily monitoring from healthcare staff, but he was very
reluctant to leave. It appears that he had friends in the unit and got on well
with the other prisoners. On 15 October, the man refused to move to F Wing.
He was given an incentives and earned privileges (IEP) warning the following
day for refusing to move. He was given another warning after writing insults
about a second HCA on the reverse of the first warning. He received further
warnings on 17 and 18 October for refusing to move to F wing and, on 20
October, was put on report. The next day, the man was reduced to the basic
level of the IEP system because of the four warnings he had received. The
first HCA explained to my investigator why she thought the man did not want
to leave healthcare:
“I got the impression that he was scared that it was his first time in
prison, he had settled in quite well on healthcare, although he had
found it initially difficult in the first few days, but he settled and made
friends. And it was the thought of actually going into a proper prison.
From talking to him, that’s the impression that I got, although they
weren’t his exact words.”
33. Another prisoner had taken his life in the healthcare department on 19
October. The man had spent time with this prisoner during association
periods and was friendly with him. The first HCA described the effect the
man’s suicide had on the man:
“He was very upset. He took it very hard, I think they had been the
closest on the landing, he had been the closest person to the
gentleman who died and he did take it hard.”
34. All of the prisoners in the healthcare unit were offered support from the
chaplain following the death. The first HCA told my investigator that the man
was a regular attendee at the chapel, and accepted the chaplain’s offer.
35. At 2.20pm on 20 October, the man refused to return to his cell in healthcare.
He became aggressive and staff restrained him and took him back to his cell.
He was taken to the segregation unit the following day for adjudication by a
governor. He was found guilty and punished with a loss of canteen.
(Canteen is the method used by prisoners to buy additional items such as
food.) He was then moved to A wing.
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36. The man threatened staff and demanded more pain relief medication on 22
October at 10.00pm. A second nurse explained that insufficient time had
elapsed since his previous dose so he was unable to have anymore. He
threw his table around in his cell and struck his leg with his crutches. The
nurse told the investigator that she considered this to be an act of anger
rather than of self-harm. She dressed his wound, which was not serious, and
provided more medication when sufficient time had elapsed. The next day,
the man was provided with a pair of trainers from reception as he complained
that the ones he had were hurting him.
37. An IEP review board considered the man’s IEP level on 25 October. Wing
staff told the review that, although the man could be difficult and arrogant, he
did not present a control problem. The man agreed to move to F wing and
was returned to the standard IEP level. He was given cell F2/01 because it
was bigger and able to accommodate his wheelchair. It was the only single
cell on the wing.
38. The first nurse who did the initial healthscreen was asked to visit the man on
F wing as he had argued with staff regarding his medication. He was
frustrated that his medication was dispensed four times a day in healthcare,
but was only dispensed twice a day on the wing. The nurse told him that, as it
was a Sunday, there was little she could do but she would organise an
appointment with the doctor for the following day. She also discussed the
possibility of using a slow-release analgesia such as Tradorec XL. This was
subsequently prescribed following his visit to the doctor.
39. The man complained to staff on 29 October that he had not received his
canteen. (This was because he had lost his canteen due to the punishment
received at the adjudication.) On 2 November, he was found guilty of the
offence committed on 20 October. Another prisoner said that the man was
bullied by three other prisoners because he had borrowed tobacco from them
and, now that he had lost his canteen, was unable to pay them back. (After
the man’s death the same prisoner also said that he heard two other prisoners
talking about the man being bullied.)
40. The prison doctor saw the man on 11 November. The man said that the
Tradorec was insufficient. The prison doctor agreed to increase the dosage
although the clinical review points out that, according to the prescription
charts, this does not appear to have happened. He explained that what really
helped with the pain was his internal pain machine. The doctor agreed to fax
the pain clinic to see if she could get a new remote control for it. She
explained to the investigator that the man had seemed calm and rational at
the time of this conversation, and she did not have concerns regarding his
wellbeing.
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41. The investigator spoke to several staff regarding the man’s time on F wing.
They consistently said that he seemed to have settled in, and raised no
concerns with them. According to them, the man got on reasonably well with
staff, but never came to them with any serious issues. Staff did not see him
being bullied or threatened and said that it was a great shock when they
heard that he had committed suicide. A note was made in his file on 15
November which said:
“Had a quiet week. No concerns to report this week.”
42. The investigator was told by prison staff that the man was sent legal papers
related to his divorce from his wife. The investigator was unable to establish
exactly when he received the papers but I understand that it was
approximately at the start of November.
43. A prisoner told the investigator that on 15 November, the night before the
man’s death, they waited in the medication queue. The prisoner said that the
man had seemed subdued as he believed he would receive a substantial
custodial sentence for his alleged offence. Overall, the prisoner thought that
the man seemed to be coping.
44. The evening roll check was completed at approximately 8.00pm by a second
officer and all was in order. (A roll check involves counting the prisoners to
ensure the correct number of prisoners are in the prison.) Following the
man’s death, the prisoners in the cell next door told staff that at approximately
11.30pm they had heard the man banging on the adjoining wall. The
prisoners said that they believed the banging to be in relation to the volume of
their music.
45. According to the report made by the paramedics, the man was last seen alive
at approximately 00.30am on 16 November. Prisoners are not routinely
checked during the night. He was found by a third officer while performing his
morning roll check at 6.55am. The officer looked through the window in the
door and saw the man sitting naked on his bed. This concerned him as it had
been a cold night. Looking closer he noticed blood on the man.
46. The officer shouted to his colleagues to issue a code red alert before he broke
his sealed key pouch and went into the cell. (A code red means a medical
emergency relating to bleeding.) He said that he was unable to find a pulse
and the man was cold. The man had cut his femoral artery which is a large
artery in the muscles of the thigh. I understand that the man used a
sharpened plastic knife to do this.
47. The officer also telephoned the healthcare department to alert them to the
emergency. The first nurse on the scene collected the emergency
resuscitation bag and went to F Wing. She went into the man’s cell and
checked his pupils’ response to light and his heart. She found no sign of life.
The paramedics arrived shortly afterwards and performed further checks.
They confirmed that rigor mortis had set in, and his heart had no electrical
activity. Rigor mortis is the stiffening of the body after death because of a loss
14
of Adenosine Triphosphate (ATP) from the body's muscles. ATP is the
substance that allows energy to flow to the muscles and helps them work, and
without this the muscles become stiff and inflexible. Rigor mortis begins
throughout the body at the same time but the body's smaller muscles - such
as those in the face, neck, arms and shoulders - are affected first. I
understand that rigor mortis normally appears within the body around two
hours after death, with the facial and upper neck and shoulder muscles first to
show its effects. However, the speed of rigor mortis is affected by a number
of factors including the size of the person and the temperature of the room.
48. The man left behind a note addressed to his wife and child. The beginning of
the letter outlines how the man felt:
“I can no longer take anymore. I have no friends, no-one to talk to. I
am alone. I do this to end what I consider to be hell.”
49. Following the man’s death, the prison worked through their death in custody
contingency plans. The Governor of Cardiff at the time, principal officer and
the prison chaplain left the prison to visit his next of kin. They informed the
man’s next of kin (his estranged wife) of his death at approximately 10.30am.
The man’s wife was not at her home and the Governor was told that she was
probably at work. They telephoned her manager on their way there, so that
support from her work was in place before their arrival. They broke the news
and then left her in the care of her manager.
50. The officer who had been appointed the family liaison officer that morning and
received a telephone call from the man’s father. He had been told of his son’s
death by a solicitor. This occurred because the man had been due to appear
at court via video link that morning, and the solicitors had been told why this
would no longer happen. (The investigator has been unable to find out why
the man was due to appear in court that day.) The investigator was told by
the family liaison officer that the man’s father was not listed in the next of kin
details in the man’s record. When the Governor arrived back in the prison,
she telephoned the man’s father. Letters of condolence were sent to the
man’s wife and father.
51. The family liaison officer arranged for the prison to pay the cost of the funeral,
and returned the man’s property to his wife. The prison chaplain was asked
by the man’s wife to officiate at the funeral. He did so, and the family liaison
officer also attended the funeral.
52. Following the man’s death, all prisoners subject to ACCT procedures on F
wing were reviewed to ensure their well-being. Listeners and the chaplaincy
was also available to prisoners who required it. The care team was
immediately deployed and staff were then able to have access to their
support. Staff that my investigator spoke to recalled the support provided to
them positively.
15
ISSUES
Assessing the man’s mental and emotional well-being
53. After any apparently self-inflicted death, it is important to consider whether
there were any warning signs that were missed.
54. Although it is difficult to tell if prisoner will be at risk of harming himself or
committing suicide when they come into prison, the man met several of the
criteria for prisoners who a particularly at risk of harming themselves.:
(cid:127) It was his first time in prison and he was accused of arson. PSO 2700
(Suicide prevention and self-harm management) states:
“There is a very strong link between charges and convictions of arson
and self-harm, particularly prolific self-harm.”
(cid:127) A further risk factor was his history of depression.
(cid:127) He had attempted to commit suicide several years earlier.
(cid:127) Another risk factor was that he was estranged from his wife, and was
served divorce papers while in prison.
(cid:127) He was upset by the death of another prisoner in the healthcare centre.
(cid:127) Another factor was the court appearance scheduled for the morning he
died. The investigator has been unable to find out the details of that
appearance, but it may have added to the emotions the man was feeling.
(cid:127) Although it is not possible to verify this view, the alleged bullying that he
underwent on F Wing provides another potential factor to add to his risk of
harming himself.
55. None of these factors alone might have been significant but cumulatively they
were and should have warranted further monitoring. Indeed, it may be that all
of them would not justify suicide and self-harm monitoring procedures.
Nevertheless, I believe that ACCT monitoring should have been considered.
The man – despite all of the factors outlined above – appeared to settle into
life in the healthcare centre and did not commit suicide until almost two
months had passed. However, he was very reluctant to move to a normal
prison wing and engaged in several breaches of discipline in an attempt to
stay in healthcare.
56. It is important that one does not criticise retrospectively and argue that staff
must have missed warning signs and are at fault for not beginning ACCT
procedures. As mentioned above, the decision on whether to open ACCT
procedures lies with the staff in contact with the prisoner. The man met many
of criteria for someone at risk of harming himself, but appeared overall, to be
coping with his imprisonment.
57. I understand that Cardiff has adopted a system where if a prisoner comes into
their custody accused of one of a number of offences, a form is automatically
opened by the Safer Custody Team. Following a specified period time, the
decision is then taken to either open an ACCT, maintain the limited monitoring
16
or end the monitoring altogether. I am pleased to hear of the pro-active way
Cardiff is attempting to identify those prisoners most at risk of harming
themselves. However, as outlined above it is not simply the offences that
someone is accused of that indicates their risk. Although I make no
recommendation, I would encourage the prison to consider whether their
system could be modified to also take into account factors such as whether it
is their first time in prison, previous history of self-harm/suicide attempts and
personal issues (e.g. family estrangement).
58. Given the close link between arson and self-harm I also suggest that the list of
offences is widened to include it.
Clinical care
59. The man’s health needs centred around his desire for medication to treat the
pain in his legs. This was provided to him and modified following
conversations with him. He was looked after in the healthcare centre during
his early time in Cardiff which I consider an appropriate means of assessing
his needs. The clinical review did not identify any significant clinical issues
regarding the man’s care although comments were made on the following
issues.
Record keeping
60. The clinical review identifies several concerns with the quality of the record
keeping in the medical records:
“The Medical Records were generally in good order, however some
entries were illegible, abbreviations were used throughout the records
and medical entries were often unsigned and lines were left blank
between entries.”
61. The clinical review includes a recommendation regarding this which I include
as:
The Head of Healthcare should ensure that the entries made in medical
and nursing records are legible, signed and that abbreviations are not
used as set out in the Nursing and Midwifery Council Guide to Record
Keeping.
62. The clinical reviewer also comments on the confusing nature of the format of
the record keeping. There were two sets of clinical records for the same
period of time and both included notes made by doctors and nurses. The
clinical review includes a recommendation relating to this which I have written
as:
The Head of Healthcare should ensure that there is either a clear
division between medical records and clinical (nursing and other
clinicians) records, or a unified record keeping approach is adopted.
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The initial healthscreen document
63. It appears that the initial healthscreen document was not fully completed. The
mental health section is empty, and there is no description of the man’s
presentation. The initial healthscreen meeting is vital in ascertaining the
immediate and ongoing health needs of a new prisoner.
The Head of Healthcare should ensure that staff complete the initial
healthscreen document in full.
The man’s practical needs
64. The nurse who did the initial healthscreen recommended that the man be
initially housed in healthcare due to his specific medical issues and because it
was his first time in prison. The nurse explained that this would allow staff to
appropriately assess his needs. I consider this to be a responsible and
sensible reaction to the healthscreen interview and a good example of staff
considering the needs of the prisoner. The disability liaison officer offered to
help the man collect the items he needed but was unable to do so before he
died. This was a compassionate offer to a man who told her that he had no-
one else who could help him and it is unfortunate that she was unable to fulfil
her offer.
65. The disability liaison officer told the investigator that, although she did not
think that the man took part in education or work, the prison would have tried
to facilitate that for him should he have wanted it. She said that education
facilities were available in the healthcare centre and the man did make use of
the reading material available to him.
Bullying
66. The investigator was told by a prisoner that the man was being bullied by
three other prisoners on F wing. The investigator enquired whether there was
any information regarding this. He reviewed the security information reports
(SIRs) and wing history sheets but there was no information regarding
bullying the man.
67. It is hard to prove allegations of bullying as it often comes down to one
person’s word against another’s. It is consequently more difficult when one of
these people has died. Staff may be unaware of bullying because prisoners
can fear reprisals if they speak up. It is not always easy to notice bullying
behaviour on a large wing with few staff. Constant vigilance is required. The
investigator was told by the third officer that, during association time, there
would usually be eight officers, and a senior officer, on duty to monitor
approximately 190 prisoners.
68. The investigator has been unable to find any evidence that the man was being
bullied, other than the information volunteered by the prisoner on F wing.
However, given the number of prisoners staff need to watch, it is impossible to
know if it was happening without the knowledge of staff.
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Use of a plastic knife
69. I understand that the man used a plastic knife to inflict the wound to his
femoral artery. A plastic knife is an item that prisoners would ordinarily be
allowed to keep in their possession. Staff would not routinely remove objects
from prisoners unless they had a specific reason to do so. This did not apply
to the man as staff did not consider him to be at risk of harming himself. Even
if staff had considered him to be at risk the knife may still have been provided
to him. PSO 2700 (Suicide prevention and self-harm management) states:
“However, removing personal belongings from a person who is feeling
hopeless and depressed … can increase feelings of distress and
therefore increase the risk of suicide, self-harm or a higher risk method
of self-harm. Where possible, prisoners at risk should be allowed to
retain their belongings unless it is clearly unsafe to do so.”
Liaison with the man’s family
70. It is disappointing that the man heard of his son’s death from a solicitor.
However, the man’s father was not listed on the next of kin details, and it is
pleasing to hear that the prison engaged with him appropriately once they
were aware of him.
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CONCLUSION
71. The man had suffered several setbacks in his life prior to being sent to prison.
He experienced depression and crippling pain in his legs, and left his job. His
relationship with the mother of his child had ended and he had attempted
suicide. The man had not expected to be remanded into prison following his
arrest for arson. However it appears that, due to the nature of his alleged
offence and the fact that he had nowhere else to live, the court felt compelled
to remand him into prison. He told staff that his hearing loss made it difficult
for him to communicate with people, and it appears that he felt very lonely in
prison. During his initial healthscreen he had told the nurse that he had no-
one outside of prison who could bring in the items he wanted. The note he
left behind reveals the depth of his unhappiness.
72. However, I do not think that any of the staff realised the extent of his feelings.
He was generally respectful to staff, albeit with some significant exceptions,
and did not approach them with any important issues. Once the man went to
F wing, staff believed that he had begun to settle into prison life. Looking at
what we now know of his life one can see that the last decade featured many
unpleasant events and his experiences in prison may have added more
stresses than he could bear. Unlike many of the deaths my office
investigates, he did not exhibit a sudden increase in risk. Instead, the tale of
his life over the last decade seems to indicate someone on a steady
downward slope.
73. While I do not consider that staff could reasonably have foreseen his death, I
do think that understanding all the aspects of his situation might well have
indicated a man at risk of harming himself. It is unfortunate that the prison did
not have the resources to take a holistic view of one man’s plight. However, I
am pleased the Cardiff has responded to the circumstances of the man’s
death and hope that the prison continue to refine their method of identifying
those most at risk of suicide and prevent future self-inflicted deaths.
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RECOMMENDATIONS
1. The Head of Healthcare should ensure that the entries made in medical and
nursing records are legible, signed and that abbreviations are not used as set
out in the NMC Guide to Record Keeping.
The National Offender Management Service accepted this recommendation:
“Head of Healthcare will issue a Notice to staff referring to medical note
entries. Also implement monthly management checks to ensure
ongoing compliance.”
2. The Head of Healthcare should ensure that there is either a clear division
between medical records and clinical (nursing and other clinicians) records, or
a unified record keeping approach is adopted.
The National Offender Management Service partially accepted this recommendation:
“There is currently joint record keeping which include Medical, Nursing
and visiting specialists. The Head of healthcare will issue a Notice to
Staff reminding them to adopt a unified record keeping approach. Also
implement monthly management checks to ensure ongoing
compliance.”
3. The Head of Healthcare should ensure that staff complete the initial
healthscreen document in full.
The National Offender Management Service accepted this recommendation:
“Head of Healthcare will issue a Notice to Staff reminding them to
ensure they complete the initial Health screen in full. Also implement
monthly management checks to ensure ongoing compliance.”
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