Individual at Norwich

Investigation into the circumstances surrounding the
death of a man at HMP Norwich in March 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2009
This is the report of an investigation into the circumstances surrounding the death of
a man at HMP Norwich in March 2008. Shortly before 5.30pm on the day of his
death, he was found hanging in his cell in the healthcare centre.
The loss of any family member is distressing but is especially so in the case of
someone who dies in prison. I offer my sincere sympathy and condolences to the
man’s family and friends for their sad and untimely loss.
The investigation was conducted by my colleague.
I also commissioned a clinical review of the management of the man’s health needs
while he was in prison custody. This was carried out by a representative appointed
on behalf of the local Primary Care Trust. I am grateful to the reviewer for her
invaluable contribution to the investigation.
I should also like to thank the Governor of HMP Norwich and the Director of HMP
Peterborough for the help they and their respective staff gave my investigator. I am
especially grateful to the liaison officers at HMP Norwich and HMP Peterborough.
When the man entered prison at Peterborough in March 2008, he was withdrawing
from drugs. He was given a reducing dosage of Methadone. Three days later, he
left the prison for court and, because all places were quickly filled, he could not
return. Instead, he was taken to Norwich in keeping with the provisions of Operation
Safeguard, the Prison Service’s contingency plan for transferring prisoners away
from establishments that have reached their capacity. At the time of the
investigation, Methadone was not available at Norwich.
I believe that the man’s death may well have been linked to the impulsiveness
associated with opiate withdrawal or with the absence of an appropriate
detoxification medication. I am disturbed by the fact that Methadone was not
available at Norwich for him, and note that since his death it has been agreed that
funding is to be provided for its introduction.
My report makes a number of recommendations that I hope will help prevent a
similar tragedy occurring at Norwich or elsewhere in the Prison Service.
This is the eighth apparently self inflicted death I have investigated at Norwich.
None of the recommendations I have made in previous reports are relevant here.
At consultation stage, the man’s family raised a number of points about which they
felt strongly and which they believed were not adequately reflected in the draft
report. These matters were put in writing to the Governor of Norwich and the
Director of Peterborough. The questions asked of both, together with the responses
received have been inserted at the end of this revised report. The man’s family also
specifically asked that the report should mention that they have been badly affected
by his loss.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2009
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CONTENTS
Summary
Investigation process
HMP Peterborough and HMP Norwich
Key events
Issues
Principal conclusions
Family concerns
Recommendations
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SUMMARY
On 7 March 2008, the man was arrested on suspicion of committing actual bodily
harm and criminal damage. He had a long history of offending and drug use and
had been in prison before. He spent a night in police custody before appearing
before magistrates the next day. A doctor who examined him thought he was
showing signs of opiate withdrawal. There was also some evidence that he had
previously self-harmed. The Prisoner Custody Officer who escorted him to court
from the police station therefore raised a suicide/self-harm warning form. At his
court hearing, the man was remanded in custody at HMP Peterborough and ordered
to appear again three days later. Upon his arrival at Peterborough, he was not
asked any questions about the contents of the suicide warning form in particular or
about his current risk of self-harm. Nor did anyone question him about his history of
alcohol abuse. However, he was placed on a Methadone detoxification regime.
The man was assessed as being fit to return to court on 11 March, but the
assessment was not based on an interview. He appeared before magistrates at
about 10.30am. He was again remanded in custody and ordered to return to court
on 8 April. Later that morning it became evident that he could not return to
Peterborough as there were no longer any vacancies. Instead, he was taken to
HMP Norwich in keeping with the provisions of Operation Safeguard, the Prison
Service’s contingency plan for re-locating prisoners away from prisons that have
reached their maximum capacity.
Shortly after appearing in court, the man had a seizure in the court cells and was
taken to hospital, where he was admitted for observation. After a few hours, he
discharged himself. He was then taken to HMP Norwich. As Methadone was not
available there, he was given Diazepam.
During his reception health screen, the man said that although he had never been a
psychiatric inpatient, but had received psychiatric treatment in and out of prison. He
also said he had tried to harm himself whilst in the community.
The man was taken to a dormitory in the First Night Centre where, at about 9.15pm,
he had another seizure. The member of the healthcare team who attended said he
was initially so concerned that he called an ambulance. However, no ambulance
arrived. The prison doctor was not called. After a short time, the man recovered.
He remained overnight in the First Night Centre without further event but, at about
8.00am the next day, he had another seizure and was admitted to the healthcare
centre.
During the morning of 12 March, the man’s behaviour deteriorated. He spat at one
member of staff and was rude to another. He was told that the observation hatch in
his cell door would have to remain in the closed position. Thus, no staff could see
him without lifting the hatch. At about 4.00pm, he was let out of his cell to make a
telephone call. A little under an hour later, he was found hanging from the toilet door
in his cell. All attempts to revive him failed. His death was pronounced at 5.21pm.
I criticise the standard of healthcare afforded to the man both at Peterborough and
Norwich especially where the assessment of his risk of self-harm and the
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management of his substance misuse are concerned. I am also critical of the fact
that he was transferred away from Peterborough after appearing in court on 11
March, thereby denying him the opportunity to continue his Methadone detoxification
programme. I believe this may well have contributed to his death.
I am pleased to be able to draw attention to the leadership shown by the Governor of
HMP Norwich, in breaking the news of the man’s death to his family in person. I also
make special mention of the prison family liaison officer for the professionalism with
which she discharged her duties in the aftermath of the man’s death.
A number of recommendations are made by the clinical reviewer. I hope these and
the one recommendation I make will help to prevent a similar tragedy occurring at
Norwich or elsewhere in the Prison Service.
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INVESTIGATION PROCESS
1. The investigation was opened at HMP Norwich on Monday 17 March 2008 by
my colleague. On that day, he met the Governor, a representative of the local
branch of the Prison Officers’ Association and a member of the local
Independent Monitoring Board. My colleague briefed those present on the
nature and scope of the investigation. He also issued notices to staff and
prisoners announcing the investigation and inviting those with information or
concerns about the man’s death to make themselves known. No one came
forward.
2. On Tuesday 1 April 2008, my colleague conducted a similar meeting at HMP
Peterborough.
3. Formal interviews were conducted with eight members of staff at
Peterborough and with seven at Norwich. Informal discussions were held with
two further members of staff at Peterborough and with one prisoner at
Norwich.
4. On 2 May, my colleague and one of my family liaison officers met the man’s
family to invite them to express any concerns they wished the investigation to
address. The concerns they raised related principally to the manner in which
the man hanged himself and the medical care he was given when he
experienced seizures. I hope his family find that I have dealt with these
matters in my report.
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HMP PETERBOROUGH AND HMP NORWICH
HMP Peterborough
5. The prison at Peterborough is situated near the town centre. Opened in 2005,
it is a private sector prison managed by Kalyx, formerly United Kingdom
Detention Services. The establishment operates as a local prison for both
male and female prisons on separate sites. It also holds young offenders. At
the time of the investigation, Peterborough could hold up to 528 prisoners in
the male prison. The male residential unit has two houseblocks comprising
four wings, each of which has two landings. All wings are self contained with
servery, showers, baths, and association space.
6. Healthcare at Peterborough is provided by Peterborough Primary Care Trust.
At the time of the investigation, Methadone was available in the establishment
as an opiate substitute for detoxification purposes.
7. The establishment was last inspected by Her Majesty’s Chief Inspector of
Prisons in October 2006. None of the issues and recommendations made in
the report of that inspection is relevant here.
HMP Norwich
8. Norwich is a multi-functional local and training prison holding adult men and
young offenders. It also has a remand unit and a resettlement unit. The
establishment serves Magistrates and Crown Courts in the east of England.
9. Between 1996 and 2004, Norwich underwent substantial reorganisation of its
wings, some of which were converted into dedicated units. As a result, the
resettlement unit, young offender units and the older prisoners unit (on the
ground floor of the healthcare centre) are all located outside the main prison.
10. Healthcare at Norwich is provided by the Norfolk PCT provider arm, now
known as the Norfolk Community Healthcare Service. The healthcare centre
has inpatient facilities and is managed by the Head of Healthcare who is
supported by a deputy and a team of nurses and healthcare officers.
11. Norwich does not have a dedicated detoxification unit. Prisoners in need of
detoxification programmes are normally managed in one of the wings or in the
healthcare centre. Prior to the man’s death, Methadone was not available for
detoxification programmes.
Her Majesty’s Chief Inspector of Prisons
12. Her Majesty’s Chief Inspector of Prisons has inspected Norwich twice in the
last three years. In her report of the earlier of those two inspections, dated
March 2005, she described Norwich as “an over-complex prison unable to
fulfil its purpose properly”.
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13. The unannounced full inspection that followed in November 2006 found that
the prison had tried, with some success, to grapple with some of the key
problems identified earlier, but in many cases these attempts had been
undermined or thrown off course by national population pressures.
14. Where suicide prevention was concerned, Her Majesty’s Chief Inspector of
Prisons said:
“Our criticisms of suicide and self-harm procedures had been fully
addressed by senior managers. We found robust systems to
support and monitor those at risk of suicide (which indeed
prevented a death during the inspection) though the prison needed
to ensure that the chaplaincy was informed and able to be involved.
Norwich had also improved its support for prisoners in the crucial
early days of custody, with better reception, first night and induction
processes. However, these pressures were significantly damaged
by the consequences of population pressure. So many prisoners
were entering the prison that not all could be held, or held for long
enough, in the first night and induction unit and many arrived late,
locked out from other nearer establishments. Crucially, at the time
of the inspection, one in five of those arriving at Norwich had spent
their first night in a police, rather than a prison, cell under Operation
Safeguard – without the benefits of any specialised support.”
15. Where detoxification was concerned, Her Majesty’s Chief Inspector of Prisons
wrote:
“Detoxification was limited to an inflexible 7 to 14 day non-opiate
based rapid intervention. Despite there being an average of 32
detoxifications a month on the adult side, no opiate based
alternative (for example Methadone) was available on reception,
even if the individual had been subject to a maintenance
programme in the community. In our survey, significant numbers of
prisoners on both the adult side indicated that they had received no
drug or alcohol support for their 24 hours in custody. In addition,
not all prisoners received symptomatic relief. One-to-links between
the detoxification team and the Counselling, Assessment, Referral,
Advice and Throughcare service (CARATs) were good, but this had
not translated into effective joint working.”
16. In respect of these observations, Her Majesty’s Chief Inspector of Prisons
made, inter alia, the following recommendations:
“The prison should update its policy for the clinical management of
substance misuse to incorporate national guidance regarding
stabilisation, detoxification and maintenance.
“All prisoners entering the prison with a demonstrable substance
misuse problem should be able to access symptomatic relief.”
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Independent Monitoring Board
17. In their annual report on Norwich for the period 1 March 2006 to 28 February
2007, the Independent Monitoring Board drew attention to no matters relevant
to this investigation.
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KEY EVENTS
Background
Arrest and police detention
18. The man was arrested in the early hours of 7 March 2008 on suspicion of
committing actual bodily harm and criminal damage. He was taken to the
police station. At about 7.50am, he was examined by a doctor who advised
that he was fit to be detained and interviewed. The doctor recorded on a
Detained Person’s Medical Form that if, after six hours’ detention, the man
needed any medication, a doctor should be called again. The doctor was
called again at 1.25am. He examined the man 45 minutes later and
prescribed 5mg Diazepam. No reason for this decision was recorded. The
doctor advised that the man could be interviewed after a further 30 minutes.
At 7.20 that evening, he asked to be given Methadone. He was examined by
another doctor who noted that he was showing signs of opiate withdrawal.
The records of the man’s time in police custody do not make clear whether he
was given any Methadone thereafter. However, the doctor advised that he
remained fit to be detained and interviewed. The doctor also noted that a
further medical review was not required.
Appearance in court
19. The next morning, the man was taken to the Magistrates Court. The Prisoner
Escort Record (PER) for the journey between the police station and the court
carried the following notations of risk:
Medical - no known risk
Security - violence
Other - drugs/alcohol, suicide/self-harm
20. The PER also recorded that the man had head-butted his cell door, had tied
cloths around his neck earlier that day, and was in the habit of taking
Methadone.
21. At his court hearing the man was remanded in custody and ordered to appear
in court again on 11 March. He was taken to HMP Peterborough that day,
arriving at about 12.50pm.
Suicide/self-harm warning form
22. A prisoner custody officer (PCO), who escorted the man between the court
and the prison, completed a suicide/self-harm warning form on which he
recorded the following information:
“DP [detained person] seems very upset at the moment. Has been
crying whilst in GSL [Global Solutions Ltd - the private security firm
contracted to escort prisoners] and seems very agitated at the
moment. DP has a history of self-harm although last attempt was
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in 2006. DP has punched cell window and has broken it and has
slight cuts to knuckles.”
Peterborough: 8-11 March
Reception
23. On duty in reception at Peterborough when the man arrived were the senior
prisoner custody officer (SPCO), another PCO, and a nurse. The SPCO took
possession of the PER and suicide/self-harm warning form and signed both
documents. At interview, he told my investigator he could only vaguely
remember the man and had no recollection of the events of 8 March when he
arrived. He said he would have passed the PER and the suicide/self-harm
warning to both the reception PCO and reception nurse. He said it would
have been highly unlikely for him to fail to do so.
First reception health screen
24. The reception nurse conducted the man’s first reception health screen shortly
after 2.00pm. She made the following electronic record of the health screen:
“Urine Methadone level positive
Adult male
Urine opiate level positive
Urine benzodiazepine level positive
Prisoner has been in prison before? Yes – ‘Peterborough did
not ask him when last here very upset and crying.’
Fit for normal location work and any cell occupancy? Yes.
Common law partnership
Prisoner has received treatment from a psychiatrist outside
prison? Yes.
Says has personality disorder but says very little about this.
Seems to be far more interested about Methadone and when he
will get this. Also has expressed that will do something to make
sure he gets it.
Refer to doctor re substance misuse.”
25. At interview, the reception nurse admitted she did not conduct a full screen.
By that, she meant that she did not ask the man any questions about his risk
of self harm, or about his alcohol abuse. She said this omission was caused
by the fact that during the reception process, he was shouting and
complaining that he needed Methadone. She thought his truculent behaviour
was due to the effects of withdrawal. She told my investigator that her lack of
concern was based on the absence of any written comments in his record.
She said she saw neither the suicide/self-harm warning form nor the PER.
However, the reception nurse referred the man to a doctor.
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Cell sharing risk assessment
26. Every new prisoner has to undergo a cell sharing risk assessment, the
purpose of which is to assess what risk the prisoner would present of harming
a cell mate if he were to share a cell. The assessment must balance his risk
of harming others against the risk of harming himself if he is left alone. The
man’s risk assessment was conducted by the reception PCO and the
reception nurse. The man told the reception PCO he had abused drugs and
was currently dependent on both drugs and alcohol. He said he was not
currently subject to Assessment, Care in Custody and Throughcare (ACCT)
procedures. (These are used by the Prison Service to monitor and manage
those prisoners who are considered to present a risk of self-harm.) The man
disclosed that he had previously been on an open ACCT form but he gave no
further details. He said he had no concerns about sharing a cell.
27. The reception nurse completed the healthcare element of the risk
assessment. In answer to the question, “Following the self-harm assessment,
have any concerns been raised?” she recorded that there were no concerns,
despite her admission at interview that she did not ask the man any questions
about self-harm. She noted in the record of the assessment that he was
“detoxing badly”.
Induction
28. Another PCO, who regularly worked in the Induction Unit, collected the man
from reception and took him to the unit. At interview, the PCO said he
remembered the man well from his previous period of custody at
Peterborough. He described him as a pleasant man but with a propensity for
getting angry. The PCO recalled that on 8 March, the man seemed agitated,
probably because he was withdrawing. He said he was not aware that a
suicide/self-harm warning form had been raised by GSL or that his PER
carried a notation of a risk of self-harm. He said that, although the man
seemed agitated, he did not behave in a manner suggestive of a risk of self-
harm.
29. The induction unit PCO also told my investigator that, once a doctor had
prescribed detoxification medication, the prisoner concerned would normally
be allocated to the detox wing if there were any vacancies. In the man’s case,
there were no vacancies on 8 March. He was therefore located in the
induction unit to await a vacancy in the detox wing. As none became
available in the wing in the short time he was at Peterborough, he remained in
the induction unit throughout.
30. The man was examined by a prison doctor at 10.30am on 9 March. The
doctor wrote in the clinical notes:
“Problem. Was on community script Methadone 60mls last Thurs.
[home area] checked with Lloyds pharmacy, seen late Sat as
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distressed. Commenced Methadone 30mls second dose Sun
morning also Diazepam script. Today no sign withdrawal
symptoms. Will need review on Monday to see if change needed.
History of poss personality disorder. No current treatment.”
31. At about 9.15am the next day, the man attended the “medical hatch”
(treatment room). He was shaking and unable to speak or coordinate his
actions. The treatment room nurse decided to take a urine sample from him.
He tested positive for Subutex, a narcotic pain reliever otherwise known as
buprenorphine, THC (tetrahydrocannibol - an active ingredient of the cannabis
plant), Benzodiazepines and Methadone. Afterwards, the treatment room
nurse assessed the man in his cell and found he had difficulty in standing and
still could not speak. She therefore asked the man to accompany her to the
healthcare centre but he refused to do so.
32. Another nurse made the following entry in the clinical notes at 9.39am:
“Refused to come to healthcare. Attended the hatch for his
Methadone still stammering. No signs of drowsiness, no breathing
problems. To come for assessment this pm. Does not want to
come to healthcare. Has been informed that he will be assessed.
Prisoner was here before and has a history of anxiety and strange
behaviour. No reason identified why he cannot talk.”
Second court appearance
33. The man was scheduled to appear at the Magistrates Court on 11 March. His
medical record contains an entry made by another at 1.16am that day
showing that she thought he was fit to attend court.
34. Both my investigator and the clinical reviewer, interviewed the nurse who
thought the man was fit to attend court. She explained that she was an
agency nurse employed to work from time to time in the healthcare centre.
She said she often completed night shifts when she would be on duty with
one other member of staff - a Prisoner Custody Officer. The nurse said she
had to use most of her shift to bring her paperwork up to date. She explained
that she made the entry in the man’s record at 1.16am because this was the
time she brought his file up to date. She admitted that she did not interview
him. In fact, she said she had never met him. Rather, she said the
assessment was based on an absence of any indications to the contrary in his
notes. Thus, she was not aware of his condition when he arrived at
Peterborough three days earlier.
35. The man’s medical record was prepared for transfer to court but was
incomplete as the administration sheet for Methadone was missing. The PER
for the journey between the prison and the court shows that he arrived at the
court building shortly after 9.00am. He was interviewed by a PCO who
recorded on the PER that he said his last act of self-harm had taken place
over two years before, and he felt alright at the moment and so there was no
requirement to raise another suicide/self-harm warning form. The man was
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interviewed by his legal adviser before moving up to the court room at about
10.30am. The magistrates remanded him in custody and ordered him to
appear before them again on 8 April.
Locked out of Peterborough
36. At 11.45am the escort staff who were to take the man back to prison were told
that HMP Peterborough could not accept any more prisoners. They were
therefore instructed to take him to HMP Norwich in keeping with the
provisions of Operation Safeguard. (This is the name given to the Prison
Service’s contingency plan for re-locating prisoners away from prisons that
have reached their maximum capacity.)
First seizure
37. The PER shows that at 11.53am, while still in court cells, the man refused
food and drinks offered to him. However, at 12.11pm he accepted a drink. A
few moments later, he was found to be having a seizure. An ambulance was
called and he was taken to the hospital where he was examined by a doctor.
At about 2.15pm, the man decided to discharge himself from the hospital after
being denied Diazepam. The doctor considered the man had recovered well
from his seizure and judged that no further medical intervention was
necessary. At 2.40pm, he boarded the escort vehicle and left for Norwich.
He arrived at the prison at about 5.00pm.
Norwich: 11-12 March
Reception
38. An officer was on duty in reception at Norwich when the man arrived. He told
my investigator that the man appeared to be jovial during the reception
procedures.
Cell sharing risk assessment
39. The reception officer and the healthscreen nurse conducted the man’s cell
sharing risk assessment. He told them he had abused drugs and alcohol and
that he was dependent on both. He said he was not currently subject to
ACCT procedures but had been in the past. He said he did not have any
concerns about sharing a cell. In answer to the question on the cell sharing
risk assessment form, “Following the self-harm assessment have any
concerns been raised?” the healthscreen nurse wrote that there were no such
concerns.
40. The reception officer noted that the man had previously been convicted of a
violent crime and that his current charge was associated with violence. He
commented on the form, “Careful monitoring of potential cellmates.”
41. At the end of his assessment, he judged that the man presented a medium
risk of harming others. In practical terms, this meant that there was no
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immediate risk but there was a need to keep the situation under review. The
man was considered suitable for sharing a cell.
Health screen
42. The nurse conducted the man’s health screen. He told her he was concerned
about “medication issues” but had no worries about his physical health. He
said he did not drink alcohol but had taken a “bag” of heroin the previous
night. It is unclear whether anything was done to verify this. He said he was
receiving “Diazepam Methadone 70mls”. He was not referred to the detox
nurse. No prescription was issued for opiate or Benzodiazepine
detoxification. No urine test was conducted at that stage as there was a
shortage of testing equipment.
43. The man gave the healthscreen nurse the name and address of his doctor in
his home area. He said he had been in prison before, and had previously
been at Norwich. He told the nurse he had been taken to hospital from court
that day “because of a fit”. The nurse noted in the man’s medical file that he
was not epileptic, but he did have “benzo” fits. The nurse noted the need to
refer him to the “drug service” but did not specify which service she meant.
44. As far as his mental health was concerned, the man said that, although he
had never been a psychiatric inpatient, he had received psychiatric treatment
in and out of prison. He also said he had tried to harm himself outside prison.
45. The nurse summarised the health screen as follows:
“Seen on reception after transferring from HMP Peterborough via
court. Had a ?? (sic) fit at court. Taken to hospital. Being detoxed
from heroin by Peterborough (drug chart at back of notes). Fit for
normal location. Will need to see GP mane [tomorrow].”
46. The investigation found that no consent to acquire medical information from
HMP Peterborough or from the man’s GP or the CADS (Community Alcohol
and Drugs Service) team was obtained. (The disclosure of any medical
information can only be made the consent of the individual concerned.)
47. A Listener was employed in reception at HMP Norwich when the man arrived.
(A Listener is a prisoner trained by the Samaritans to offer support to other
prisoners at times of distress.) The Listener told my investigator he had
known the man for about five years and recognised him as he came through
reception. The Listener said he spoke to him that evening as a friend rather
than in his role as a Listener. He said he thought he was perfectly alright at
that time, although he was frustrated that he was not getting his medication.
Allocation to First Night Centre
48. The man was assessed as being fit normal location (i.e. on a wing rather than
in the healthcare centre or other specialist unit) despite his drug dependency
and his history of convulsions and self-harm. He was therefore allocated to
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the First Night Centre. The reception officer took him across to the unit. In a
statement submitted to the Governor after the man’s death, the reception
officer wrote that the man told him he would be having fits that night as his
medication had been inconsistent over the last day or so. He said he hated
having the fits.
49. That night, only two options were available for the man’s location in the unit.
There was a bed available in a double cell and another available in a four-bed
dormitory. A senior officer was the manager in charge of the unit. The
manager of the unit told my investigator that during her interview with the man
he said that, because he had trouble with some African prisoners at
Peterborough, he did not want to share a cell with anyone who was not white.
She explained that as the prisoner occupying the double cell was not white,
she decided to locate the man in the dormitory where there were two other
white prisoners. He remained in the dormitory that night.
50. The manager of the unit estimated that the man arrived in the First Night
Centre at about 7.00pm. She conducted an induction interview with him
shortly after allocating him a bed in the dormitory. She told my investigator
that he appeared to her to be perfectly normal. She also described him as
being jovial. She emphasised that he gave her no impression of withdrawing
from drugs. She did not know that he had been taken to hospital from court
earlier that day after having a seizure.
51. During his induction interview, the man told the manager of the unit that,
although he had self-harmed in the past, he did not currently feel suicidal.
However, he was worried about his girlfriend who was pregnant. The
manager of the unit said that, despite this, he gave her no cause for concern.
She went off duty at about 8.15pm and was not on duty the next day.
Second seizure
52. At about 9.15pm, the staff in the First Night Centre discovered that the man
was having a seizure. They called the healthcare centre to ask for someone
to examine him. A staff nurse attended and was sufficiently concerned about
the man to ask for an ambulance to be called. When, after about 15 minutes,
no ambulance arrived, the staff nurse rang the control room to find out what
was happening. He was told that no ambulance had been called.
53. The person on duty in the control room that night was an officer. At interview,
the control room officer explained that his shift began at 8.00pm that evening
and finished at 7.30am the next day. He showed my investigator the
communications room log book for that night. The log book contained the
following entry made against the time of 9.00pm: “ [the man] fitting in cell E2-
01. Hotel 2 and Oscar 1 in attendance. Treated by Hotel 2 in cell.”
54. The control room officer was adamant that no one asked him to call for an
ambulance that night in relation to the man. He said that, had he been asked
to do so, he would have logged the request. However, he admitted during
interview that the person who called over the radio did indicate that the
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message was a “code blue”. (This code is used to indicate that a potentially
life threatening situation has been discovered.) He said he forgot to enter this
fact into the log.
55. The control room officer told my investigator that he was not automatically
required to call for an ambulance when he received the code blue message.
He said the decision as to whether an ambulance is required is made by the
staff present at the cell. He said the Orderly Officer rang him at about 9.20pm
and asked him where the ambulance was. He replied, “What ambulance?
None has been requested. I will phone one.” He told my investigator that,
just as he was about to call for an ambulance, the Orderly Officer said to him,
“Don’t bother, the situation is under control.” The control room officer
admitted that he did not make a log of that communication.
56. In the meantime, the staff nurse returned to the healthcare centre to find the
man’s medical notes. He found a prescription for Diazepam that had been
made out at Peterborough. He used that prescription as an authority to
administer the medication to the man. The staff nurse did not consider
seeking advice from a doctor. Although he told my investigator he left
instructions for the night staff to “keep an eye on” him during the night, the
investigation found no written evidence in support of this. The man had no
further difficulties that night. Details of these events were not properly entered
into his medical record.
Events on 12 March
Third seizure – admitted to the healthcare centre
57. At about 7.45am the following day, a prisoner in the same dormitory as the
man pressed the cell bell to alert staff to the fact that he was having another
seizure. An officer, one of the staff on duty in the First Night Centre at the
time, later wrote in a statement:
“On 12 March I came on duty at 7.15am into E Wing. At approx
7.45am, a cell bell E2-001 was pressed followed by banging on the
cell door and shouting. Myself, [two officers named] went to
investigate. On entering the cell the man was laying on his bed
having an epileptic fit. We made sure he was safe from injury, i.e.
not falling off his bed or banging his head and called for medical
assistance. At no stage did the man fall off his bed or hit his head
during his fit. Medical assistance arrived soon after and took over.”
58. Another staff nurse responded to the call for assistance. She confirmed that
the man appeared to be experiencing a seizure and arranged for his transfer
to the healthcare centre for observation.
59. The healthcare senior officer was on duty in the healthcare centre when the
man was admitted. He said in a statement:
17
“At approx 10.00am the man was admitted onto my unit due to
medical issues from the night before and was located by staff into
cell H2-15. After a short time he was asked if he would like to go
on exercise with the other prisoners. He accepted. He
commenced exercise at approx 10.25am. At approx 10.30am he
returned to the landing. When asked why he returned he stated he
had felt physically sick in the fresh air and wanted to see the doctor
as soon as possible in order to sort out his medication.”
Deterioration in behaviour
60. The healthcare officer (HCO) was also on duty in the healthcare centre that
day. In a statement made out later, he gave the following account of events
that morning:
“On 12 March, I was on duty on the healthcare landing. At
approximately 10.00am the man was brought up to the landing as
admit. We located him in cell H2-15. At approximately 10.25am,
he attended our exercise period. He was seen by the doctor
between 10.30am and 11.00am.”
61. A healthcare staff nurse was with the doctor who assessed the man. She
made the following entry in his medical record:
“Was seen today by the doctor. Is alert today. Walks around and
also hits the window of the landing. He says he wants to damage
the place if he has to stay here. Gets prescription for rectal
Diazepam and will be on a detox scheme.”
62. During his consultation with the doctor, the man became aggressive and,
according to the HCO, “stormed” back into his cell. On the way, he kicked two
cell doors. The HCO went to his cell and found the senior healthcare officer
was already speaking to the man and attempting to calm him down. The
healthcare principal officer had also gone to the man’s cell. The HCO
therefore returned to the landing office.
63. The investigation found that no note had been made of the last time the man
had received either Methadone or Diazepam. No withdrawal monitoring or
formal observation chart was put in place.
Assault on the healthcare principal officer
64. The healthcare principal officer made out the following incident report form:
“At approximately 10.55 hrs on 12 March, I was talking on the
phone in the healthcare office when the man walked into the office
and said if he wasn’t taken back to the adult site he would smash
his cell up. When I had finished the telephone conversation, I went
to see him in his room to explain why he had been admitted to the
18
healthcare centre. He stated that if he wasn’t returned to the adult
centre he would harm himself. I stated that it would be his choice
and again explained why he had been admitted to the healthcare
centre. He then spat in my face. I left the room and attempted to
shut the cell door. He continued to kick the door violently,
preventing me closing it.”
65. The healthcare principal officer placed the man on a disciplinary report. He
also referred the matter to the police. A disciplinary hearing was scheduled to
take place during the afternoon of 13 March.
66. At interview, the healthcare principal officer said he thought the comment the
man made about self-harming was more associated with his “temper tantrum”
than with any serious intention to harm himself. He said neither he nor any
other members of staff on duty in the healthcare centre that day thought the
man was at risk of self-harm or suicide.
67. The healthcare staff nurse told my investigator that, after a few minutes, the
healthcare senior officer returned to the cell to see if the man was alright. He
spoke to him through the cell door. The man told him he would not behave
aggressively any more. He opened the observation hatch in the door so that
he could see the man and asked him why he had become so upset. The man
told him he was frustrated and did not mean to shout or cause trouble. He
also offered to apologise to the healthcare principal officer for spitting at him.
The man was due to attend a secondary health screen that day, but refused
to do so.
Admission to healthcare centre
68. The healthcare staff nurse made the following entry in the man’s nursing care
plan. She wrote:
“Fits on the wing (see system 1) transferred to HCC [healthcare
centre] for observation. Commenced on Diazepam detox. Not
happy to be in HCC. Has assaulted a member of staff by spitting.
Hatch to remain up at present.”
69. In his statement to the Governor, the HCO explained what happened next.
He wrote:
“Shortly after this, the man put on his cell bell. I answered it and he
asked me about his medication. I told him the medication would be
issued to him as soon as we received it from the pharmacy. During
the lunch time patrol period, he put on his cell bell. It was
answered by a nurse. Following their brief conversation, the man
was abusive to [the nurse who answered his cell bell]. As a result
of this I had no choice but write an advice notice.”
19
An advice notice is issued to any prisoner whose behaviour has become a
matter of concern to staff. At the top of each notice, the following text is
included for the information of the prisoner concerned:
“There are some problems with your conduct. These are
highlighted below. Should these concerns continue you will be
issued with a Warning Notice. This could lead to a change in
regime.”
70. The HCO further explained:
“At 2.30pm, [the healthcare staff nurse] issued the man his
medication. I accompanied her. He took his medication without
incident. As we left I realised I had not issued him with his advice
notice so I returned to his cell. I unlocked his hatch and issued him
with the notice. He asked what it meant so I explained the IEP
[Incentives and Earned Privileges] system. He asked if he could
have his hatch down. I explained that until we could be sure he
would not abuse the privilege of having the hatch open, it would
have to remain shut.
“Between 3.00pm and 4.00pm, the man put his cell bell on twice.
Firstly to request some toiletries which he was issued. Secondly to
use the landing telephone. I unlocked him and he went to the
phone. He called me for assistance because he could not get
through to his number. I tried for him and also could not get
through as the system stated the number he was ringing was not
authorised. I told him I would ring the PIN [Personal Identification
Number] phone clerk and find out why it would not work, which I did
after I returned him to his cell. The PIN phone clerk informed me
that [the man] would need to fill in a phone list application form. I
took the form down to him in his cell. I went into his cell and
explained why his number was blocked and that if he filled in the
form, I would get it processed as soon as possible. He apologised
to me for his behaviour earlier in the day and told me that he was
hoping to get judge in chambers and bail the next day. I asked him
what he was on remand for and he told me it was for an assault on
an ex-prisoner. We spoke for a short while about when he was on
A Wing before it was closed. At this point his mood seemed more
settled. I left the cell but returned between 4.05pm and 4.15pm
because I realised I still had his PIN phone number in my pocket. I
gave it to him and he thanked me. I then left the HCC to collect the
evening meal.”
The HCO was the last person to see the man alive.
The man found hanging
71. At approximately 4.50pm, the HCO and his healthcare colleague began
unlocking the doors on the landing to serve the evening meal. About four
20
minutes later, the healthcare colleague unlocked the man’s cell and found him
in a sitting position suspended by a ligature fashioned from a bed sheet and
tied to the handle of the toilet door. The toilet door had been pulled almost
shut so that he was partially out of view. The HCO cut the ligature with an
anti-ligature knife and, with the assistance of the healthcare principal officer
and the healthcare colleague, lowered the man to the floor.
72. The healthcare colleague checked for signs of life but there was none. He
began mouth to mouth resuscitation and cardiac massage and told the HCO
to fetch the emergency bag. By the time the HCO returned to the cell with the
emergency equipment, the healthcare manager had arrived and had
commenced Cardio Pulmonary Resuscitation (CPR). The following extract
from a statement she made out later explains the healthcare manager’s
actions:
“When I got to the cell door, I saw the healthcare colleague
preparing a bag for the patient. The male patient was lying on the
floor with his head facing the cell door. He was laying on his back
fully clothed. I noticed that he was purple from the neck up and his
body was warm. The male patient’s name is [the man’s name]. I
commenced CPR on him and while carrying this out my colleagues
told me that [the HCO] had cut the sheet while the healthcare
colleague supported the body. We carried out CPR with the
paramedics arriving at 17.05 as stated in the primary survey. I then
continued CPR while paramedics inserted lines into him. The
healthcare staff nurse then took over chest compressions while I
took over managing the airway. After a few minutes I took over
chest compressions again and the senior healthcare officer took
over the airway. Paramedics took over the chest compressions
and airway at about 17.15hrs. We had been using our defib
machine was used from the two minutes after I arrived (sic). The
defib machine ran 5 cycles with no shock indicated. Paramedics
had given 3 lots of adrenalin i/v and 1 atropine during the process.
They also put up a drip to give [the man] a fluid challenge. At 17.21
hrs it was a team decision to discontinue CPR. He was in asystole
throughout which means no heartbeat. The paramedics
pronounced him dead at 17.21hrs.”
(An ‘airway’ is an instrument that is inserted into the throat to enable
oxygen to be passed into the lungs. The term ‘defib’ refers to a
defibrillator, a portable electronic device that diagnoses potentially life
threatening abnormal heart rhythms.) The healthcare manager’s
statement continues:
“Prior to leaving the cell I noticed a piece of paper on the table
under the cell window. I didn’t touch the note but read it. It said,
‘Dear [name removed], I’m sorry, I can’t do this any more. Please
take care of my body.’ I think there were kisses but I cannot
remember. The note was left in the cell.”
21
73. The Roman Catholic priest said prayers for the man in his cell.
Informing the next of kin
74. The prison’s family liaison officer (FLO) was at home when the man died. At
5.30pm, she was called by the prison and asked to join the Governor in the
command post. Upon her arrival at 6.30pm, she was briefed by the Governor
who decided that he and the prison FLO should both break the news of the
man’s death to his family in person. A document in the man’s prison record
showed his brother was his next of kin. The Governor and prison FLO left the
prison at 7.30pm and arrived at the man’s brother’s house shortly after
8.00pm. His brother, girlfriend and sister-in-law were at home when they
arrived. The Governor broke the news of the man’s death to them, and both
he and the prison FLO remained with them until it was appropriate to leave.
75. The Governor later wrote a letter of condolence to the man’s family. This was
delivered to them by the prison FLO in person.
Prisoner and staff support in the aftermath of the man’s death
76. The cases of all those prisoners who were subject to ACCT procedures at the
time of the man’s death were reviewed afresh.
77. Members of the prison’s care team were on hand to offer support to the staff
involved in the discovery of the man and in attempting to revive him. Those
staff who were interviewed confirmed they were content with the support
offered.
Ongoing family support
78. In liaison with the Coroner’s office, the prison FLO helped to arrange for the
family to view the man’s body at the mortuary on 14 March. The prison FLO
supported the family in person before and after the viewing.
79. The man’s funeral took place at 10.00am on 26 March at a Roman Catholic
church in his home area. The prison FLO and the deputy governor
represented the Governor at the funeral service. A wreath was sent to the
undertakers from the prison with the agreement of the man’s family. The full
costs of the funeral were offered to the family
80. On 3 April 2008, the man’s brother and other members of his family viewed
the cell in which he died. With their agreement, and with the permission of the
Coroner, a copy of the letter the man left for his family was given to them that
day.
22
ISSUES
81. Here I examine the following:
(cid:127) Whether the man’s health needs were properly assessed and managed. I
place particular emphasis on the extent to which the effects of his drug
abuse were identified, monitored and managed.
(cid:127) Whether his risk of self-harm or suicide was properly assessed, monitored
and managed.
(cid:127) Whether the response to the discovery of the man hanging was prompt
and effective.
(cid:127) Whether appropriate courtesies were offered to the man’s family in the
aftermath of his death.
Were the man’s health needs properly assessed and managed?
82. The clinical reviewer in her report says:
“Having reviewed the care that [the man] received from the point of
his arrest and placement in police custody to his death on March
12th 2008, it can be concluded that a number of key healthcare
interventions were either omitted or not undertaken adequately.
These collectively resulted in some aspects of the care [he]
received falling short of the standard required for the care of
patients with substance misuse issues and who may be at risk of
self-harm/suicide.”
HMP Peterborough
Reception health screen
83. The clinical reviewer has found:
“The reception screening was taken by a healthcare assistant. No
formal assessment training is given other than a session on what is
included in the screening as part of the induction of new staff. A full
reception screening was not completed because of [the man’s]
‘distressed state’ and because he was referred to the GP urgently.
Some important information was not captured, such as [his] history
of self-harm, his history of alcohol consumption, his smoking status
and his current physical health. When transferred from police
custody to court, [the man’s] Prisoner Escort Record (PER) showed
he was assessed as presenting the following risks:
Medical – no known risks
Security – violence
Other – drugs/alcohol, suicide/self-harm
“The form was not signed by a Prison Officer on arrival at HMP
Peterborough but the information was not available during his initial
23
reception screening. [The man] was placed in normal location
because his risk assessment confirmed that he was not at risk of
self-harm. The nurse had not asked [him] for any past medical
history regarding self-harm and his PER showed he had notations
of risk, including self-harm and suicide.”
84. I endorse the following recommendation from the clinical review:
HMP Peterborough must review its policies and procedures for first
reception screening to ensure these meet national guidance.
Documents which would be useful are:
Prison Service Order (PSO) 3050 - Continuity of Healthcare for
Prisoners
PSO 1025 - Communicating information about risks on escort or
transfer
PSO 3550 - Clinical Services for Substance Misusers
PSO 0500 - Reception (section 4 and section 6)
Clinical Management of Drug Dependence in the adult prison setting
Particular note should be taken of the provisions of paragraph 4.4 of
PSO 0500 and paragraphs 1.2 and 1.4 of PSO 1025 which set out
guidance on the use of Prisoner Escort Records. Prison healthcare staff
who are responsible for undertaking first reception screening should be
appropriately qualified and receive regular training and
supervision in effective assessment of prisoners.
Clinical assessment
85. The clinical reviewer judges as follows:
“The system in place for confirming that a prisoner is fit for court
was discussed with the nurse responsible. There was no protocol
available that described the process for assessing a prisoner’s
fitness for court. The review is a ‘virtual’ review using prisoners’
medical records. It does not include a face to face assessment.
This was a task which was performed by the night staff and there
could be a large number that needed signing off each night. [The
man] did not receive his daily dose of Methadone prior to leaving
for court because of an error on his medical chart.”
86. I endorse the following recommendation:
HMP Peterborough should review their processes to ensure that
prisoners are seen as close to discharge as possible to confirm their
fitness to attend court. The review should include ensuring that
prisoners who require medication have received this prior to leaving
and that all necessary documentation accompanies the prisoner.
24
Record keeping
87. The clinical reviewer has found:
“The entry ‘fit for court’ did not include any reference to the
concerns regarding [the man’s] condition the previous day. His
medical record was prepared for transfer to court but was
incomplete as the administration sheet for Methadone was missing.
HMP Norwich does not currently give Methadone. The impact of
this omission was that there was a lack of clarity as to [his] current
medication and when he was last given Methadone.”
88. I therefore endorse the following recommendation:
The current process in place for confirming a prisoner’s fitness for
court must be reviewed to ensure that where prisoners have particular
healthcare issues such as substance misuse these are taken into
consideration.
HMP Peterborough should ensure that the provisions of paragraph 5.3
of Prison Service Order 3050 are followed when prisoners are
transferred to court so that they have a summary of relevant medical
details available. Where possible, this should be followed up with
telephone communication confirming current health issues.
The decision to transfer the man to HMP Norwich under Operation Safeguard
89. As noted earlier, Operation Safeguard is the name given to the Prison Service
contingency plan for relocating prisoners away from prisons that have
reached their maximum capacity. The procedures to be followed when it is
necessary to invoke the plan are set out in Prison Service Instruction (PSI)
30/2006. The following is an extract from the PSI:
“5.3 Every effort must be made to avoid the use of police cells for
the following groups of prisoners. In every case, when a prisoner
from one of these groups is discharged from prison to court, his/her
PER form must be endorsed ‘return to discharging establishment’.
Juvenile prisoners
Female prisoners
Those at risk of self-harm on open ACCT forms
Those with significant healthcare issues, including
- prisoners undergoing assessment for, or are due transfer
under the MHA 1983
- any prisoner identified by the prison health team as unsuitable
on clinical grounds. [This must be clearly identified on the
PER.]
- any other prisoner with a significant physical or mental health
25
problem that the healthcare provider to the police station feels
is clinically unsuitable for their locally available service. E.G.
clinically unstable substance misuse problem or a patient
undergoing complicate treatment.”
These conditions were not applied to the man.
90. A Notice to Prisoners is appended to the PSI. The following extract can be
found at paragraph 3 of the notice:
“Spaces retained at establishments
You may not be able to return to the establishment due to
population pressures. Spaces will only be kept for:
Crown Court productions
Those returning from the Court of Appeal (Criminal
Division)
Those requiring special care for medical reasons.”
91. The provisions of the PSI were not applied in the man’s case. His Prisoner
Escort Record (PER) carried no endorsement of a need for him to return to
Peterborough even though he had a “clinically unstable substance misuse
problem”. During his absence from the prison, no space was kept for him. It
is not clear why this was the case. In my view, the wording of the PSI is such
that the man was eligible to be returned to Peterborough after his court
appearance because he was withdrawing from drugs and was subject to a
Methadone detoxification regime. It is possible that the failure to retain a bed
for him at Peterborough and to endorse his PER may have been either based
on an oversight or on an assumption that he was ineligible.
92. My investigator consulted the Prison Service’s Population Management Unit
(PMU) about the PSI. He was told that its provisions could have been applied
in the man’s case. However, had his PER been endorsed with an instruction
that he was to return to Peterborough, it could not have been guaranteed.
This was because of a need for the escort contractor to prioritise the most
pressing cases within the overall number of prisoners who were eligible. This
suggests that the force of the PSI has been weakened by operational
pressures. The investigation also found that the thrust of the PSI is directed
towards the need to avoid the detention of prisoners in police stations. It does
not cater for those, like the man, who may be transferred to another Prison
Service establishment rather than to a police station after being locked out of
the discharging establishment. In the man’s case, this resulted in the
disruption of his detoxification regime.
93. I find it unacceptable that the man was unable to return to Peterborough to
continue his Methadone detoxification regime after his court appearance on
11 March. Equally unacceptable was the fact that, having transferred to
Norwich, he found himself in an establishment that could not offer the same
detoxification regime. This could be avoided in the future by revising
26
paragraph 5 of PSO 3050 so that it makes clear that those prisoners for whom
‘clinical hold’ is necessary include those subject to detoxification regimes.
This latter recommendation is made by the clinical reviewer in her report. I
repeat her recommendation here:
HMP Peterborough should review their policies in line with PSO 3050,
‘Continuity of healthcare for prisoners’ to ensure that prisoners who
have not completed opiate stabilisation are able to receive continuity
of care either through clinical hold of their accommodation or by
ensuring that the receiving prison is contacted.
This guidance covers the facility to agree a ‘clinical hold’ on
accommodation for patients whose clinical condition is such that they
would be at risk if transferred. It states at paragraph 5.5, ‘patients may
need to be placed on clinical hold (i.e. withheld from transfer for a
period of time for clinical reasons when indicated.’
This should be nationally reviewed to ensure that a clinical hold is
available for remand prisoners who have commenced substance
misuse stabilisation, to ensure they are able to return (to the
discharging establishment) if courts decide to continue custodial
arrangements.
HMP Norwich
Reception health screen
94. The clinical reviewer comments as follows:
“A full reception screening was not completed. Questions
regarding alcohol consumption were not asked. [The man] was
recorded as being a substance misuser. His medical record and
prescription charts were available to the reception nurse although
the prescription chart did not include his admission sheet. No urine
test was undertaken because of a shortage of testing equipment.
No referral was made to the detox nurse. No prescription was
issued for either opiate or benzodiazepine detoxification. The last
time [he] received any medication to manage his drug dependency
was not noted. He indicated during his screening that he had a
history of self-harm, no ACCT form was initiated. No consent to
obtain medical information from HMP Peterborough, the GP or the
CADs team was obtained.
95. The man was assessed as being fit for normal first night location despite his
unmanaged drug dependency and history of convulsions and self-harm.
HMP Norwich must review the content and implementation of the
policies and procedures in use at first reception screening to ensure
these meet national guidance. Documents which would be use would
be:
27
Prison Service Order (PSO) 3050 – Continuity of Healthcare for
Prisoners
PSO 3550 – Clinical Services for Substance Misusers
PSO 0500 – Reception (section 4 and section 6)
Clinical Management of Drug Dependence in the adult prison
setting (published in November 2006).
In particular, policies regarding recognition, management and
stabilisation of prisoners who are receiving Methadone substitution
and benzodiazepam detoxification should be reviewed and
implemented.
First reception processes should be audited regularly for quality
assurance and to confirm full implementation.
Prison healthcare staff who are responsible for undertaking first
reception screening should be appropriately qualified and receive
regular training and supervision in effective assessment of prisoners.
Access to a medical practitioner should be available to all prisoners
who require to be seen on the day of their arrival. This might be
delivered by reviewing current surgery hours to ensure that cover is
available in the afternoon to see all prisoners who require to see a
doctor during normal primary care hours of 8.30am to 6.00pm.
Managing emergency medical events
96. The clinical reviewer writes as follows:
“[The man] was observed as having had convulsions, the cause of
which was unclear. Medical advice and/or review were not
obtained. It was recognised that [he] was an opiate substance
user. However, no formal arrangements were made him to be
observed and no opiate scale was initiated.”
HMP Norwich should put into place protocols and care pathways for
managing emergency medical events. This should include the
requirement for requesting external medical assistance in acute
medical events such as unexplained convulsions. Healthcare staff
within normal cell location should receive regular training and
supervision in the emergency assessment and treatment of prisoners
who present with acute medical events. Staff should receive training
in the management of prisoners at risk of opiate withdrawal which
includes the use of opiate withdrawal scales for monitoring their
condition.
During the investigation, the man’s family expressed their concern that they
were not consulted about his history of experiencing seizures. They
believed that, had this happened, they might have been able to provide
28
valuable information that could have been relevant to his management.
Although I make no formal recommendation on this point, I nevertheless
believe that the family have raised an important point that healthcare staff
may wish to take into account in future. I believe that the involvement of
families, with prisoners’ consent, is good practice.
Management of medicines
97. The clinical reviewer has found that the man was given medication which did
not agree with that prescribed by a doctor at Peterborough. The drug was
correct but the dosage was half of that prescribed.
Healthcare staff should familiarise themselves with medicines
management to ensure that they administer medication in line with
professional legal requirements.
Record keeping
98. The clinical reviewer concludes as follows:
“Insufficient explanations were recorded in [the man’s] medical
record with regard to the request and non-attendance of an
ambulance (on 11 March when [he] had his first seizure in the
prison) and later Medicom. The suggestion made to [him] that he
should be transferred to the healthcare centre was not recorded.
The need for and the frequency of observations to be carried out on
[him] was not recorded in his medical records. There was no follow
up or review plan.”
HMP Norwich should have in place both protocols and training
available to staff to ensure that record keeping is standardised and
includes all relevant information including plans of care management
and patients’ choices with regard top health intervention.
Calling an ambulance
99. I agree with the clinical reviewer’s recommendation about the record keeping
aspect of the non-attendance of an ambulance. I would add that the fact that
an ambulance was not called when initially requested is a significant failure.
Although on the evening of 11 March after he had a seizure, the man made a
full recovery such that the ambulance was no longer required, a similar failure
in the future could contribute to an avoidable death.
The Governor should review his contingency plans for calling for an
ambulance and ensure that effective drills and procedures are put in
place and rehearsed by control room and other key staff.
29
100. The clinical reviewer has further noted that the computerised medical record
for the man was not available during consultation. She adds:
“No care plan was present in the medical records presented for the
clinical review. No review date was made for [the man]. No
request was made for further information. No request was made
for any further tests regarding substance mis-use.”
HMP Norwich should review its policies and audit the successful
implementation of medical records systems to ensure that they meet
the current national requirements of Records Management – NHS Code
of Practice (Department of Health, published April 2006)
Clinical assessment
101. The clinical reviewer has found:
“On 12 March there was no note made of the last dose of either
Methadone or Diazepam [the man] had received. There was no
comment or plan of how to manage any withdrawal symptoms
resulting from the omission in receiving his usual medication. [The
man’s] GP was not contacted to confirm current Methadone
consumption either before or as a result of his consultation. This
may have been undertaken at a later stage. No withdrawal
monitoring or formal observation chart was put in place.”
Clinical assessment of patients with substance misuse issues should
follow national guidance set out in Clinical Management of Drug
Dependence in the Adult Prison Setting published by the Department
of Health in November 2006. This will require a review of the current
(local) policy which was published in May 2006 and has not been
reviewed to date. An interim review of policy must be undertaken and
an implementation plan put in place as a matter of urgency and should
reflect the current situation that HMP Norwich does not currently
undertake (opiate) substitution prescribing.
Prisoners currently receive the majority of their care within normal
location (i.e. on a wing) and consideration must be given to ensure that
primary care within normal location is sufficiently resourced in terms
of environment and staffing to provide a safe service.
Detoxification medication management
102. The clinical reviewer has found that a Diazepam detoxification regime was
commenced but not given to the man as an urgent medication. No opiate
regime was discussed. No reason for refusal to commence was made clear.
Prescribing management for substance mis-users should follow
national guidance set out in Clinical Management of Drug Dependence
in the Adult Prison Setting. This will require a review of the local
30
policy which has not been updated since May 2006. Protocols should
be available in all clinical areas and should be part of prescribers’
training and induction.
Closure of cell observation hatch
103. The man’s observation hatch was closed during the afternoon because of his
aggressive behaviour.
HMP Norwich healthcare policy and protocol for management of
prisoners with substance mis-use should reflect national guidelines
with regard to the closure of observation hatches for prisoners
receiving substance withdrawal management. This can be found in
the Clinical Management of Drug Dependence in the Adult Prison
Setting.
Managing challenging behaviour
104. The clinical reviewer has noted that the man was placed on a disciplinary
report for spitting at an officer and then issued a warning for unpleasant
behaviour towards staff. She makes the following recommendation that I
endorse:
HMP Norwich healthcare staff and prison officers (working in the
healthcare centre) should receive training on the management of
challenging behaviour in prisoners with substance misuse issues.
105. However, whilst I accept that there may be a training need here, I do not
criticise the healthcare principal officer for taking formal disciplinary action
against the man for spitting at him. This was a wholly unacceptable form of
behaviour that no member of staff should have to tolerate. All decisions to
use formal disciplinary measures are inherently discretionary. But the
purposes of formal discipline include the protection of staff and the setting of
standards for all prisoners. For those reasons, a decision to charge the man
could be justified notwithstanding that he was withdrawing from drugs.
106. I should emphasise that the recommendations listed above should be
considered in conjunction with the full list of recommendations shown on
pages 22 - 27 of the clinical review itself.
Was the man’s risk of self-harm or suicide properly assessed, monitored and
managed?
107. When the man arrived at Peterborough from court on 8 March, his Prisoner
Escort Record (PER) contained a notation that he was at risk of self-harm
because, earlier that day, he had apparently head butted the door of his cell at
the police station and had tied cloths around his neck. A Prisoner Custody
Officer (PCO) had also raised a suicide/self-harm warning form because the
man had admitted that he had a history of self-harm and had cut his knuckles
as a result of damaging his cell window with his fists. Although the warning
31
form was signed by the reception staff, the investigation found no evidence
that its contents were considered.
108. The nurse who conducted the reception health screen shortly after the man’s
arrival admitted to my investigator that she did not ask him any questions
about his risk of self-harm. She said this omission was caused by the fact
that, during the reception process, he was shouting and complaining that he
needed Methadone. She also said she saw neither the suicide/self-harm
warning form nor the PER. These are unacceptable failures which must not
be repeated.
109. No ACCT form was opened on this occasion. It does not follow that had the
man’s risk of suicide or self-harm been properly assessed at Peterborough,
there would have been grounds for opening one.
110. During the induction process at Norwich, the man told a member of staff he
did not feel suicidal. Thereafter, he manifested risk behaviour on one
occasion. This was at approximately 10.50am on 12 March after he had been
admitted to the healthcare centre at HMP Norwich, when he threatened to
harm himself unless he were returned to a wing. The staff believed this was
more the result of a “temper tantrum” than of any active suicidal ideation. It is
easy, with the benefit of hindsight, to judge against that view. However, I
believe that, at the time, it was reasonable for staff not to open an ACCT form.
111. After the man was discovered hanging, a note was found in his cell that
indicated his inability to carry on living. This suggests that he made a
conscious decision to end his life. I believe that, however much he may have
known what he was doing at the point of making that decision, the man was
likely to have acted on impulse at a time when he was not receiving
appropriate detoxification medication. My experience of other investigations
has shown that there can be a relationship between drug misuse and risk of
self-harm or suicide. I believe this to have been the case where the man was
concerned. I urge the Director of Peterborough, the Governor of Norwich and
the PCT to take seriously the comments and recommendations made in the
clinical review and to implement the recommendations urgently.
Was the response to the discovery of the man’s hanging prompt and
appropriate?
112. The man was found hanging in his cell at about 4:55pm on 12 March by the
healthcare colleague. He entered the cell straightaway, calling for assistance
as he did so. His colleague the HCO cut the ligature from the man’s neck with
no delay. He and the healthcare principal officer laid him on the cell floor and
checked for signs of life. Finding none, they applied CPR and continued to do
so until an ambulance crew arrived approximately 10 minutes later. The
healthcare manager arrived at the cell very soon after the man was
discovered and assumed responsibility for co-ordinating the efforts of prison
staff to attempt to save his life. The paramedic crew continued to apply
advanced life saving techniques for a further 15 minutes. Sadly, their efforts
were in vain. The man’s death was pronounced at 5:21pm.
32
113. The man’s family were concerned to be told as much as possible about the
manner in which he hanged himself. Unfortunately, those who were
interviewed by my investigator were unable to explain this in any detail.
114. I am satisfied that the response to the discovery of the man hanging was both
prompt and appropriate. I commend those staff who tried to revive him for
their determined efforts in very harrowing circumstances.
Were appropriate courtesies offered to the man’s family in the aftermath of his
death?
115. The Governor and his family liaison officer (FLO) broke the news of the man’s
death to his brother at their home,in person at about 8:00pm on 12 March.
They both stayed with the family until it was appropriate to leave. The
Governor later wrote a letter of condolence to the family. This was delivered
to them by the prison FLO in person.
116. In liaison with the Coroner’s office, the prison FLO helped to arrange for the
family to view the man’s body at the mortuary on 14 March. She supported
the family in person before and after the viewing.
117. The prison FLO and the deputy governor represented the Governor at the
funeral service that took place on 26 March. A wreath was sent to the
undertakers from the prison with the agreement of the man’s family. The full
costs of the funeral were offered by the Governor.
118. On 3 April 2008, the man’s brother and other members of his family viewed
the cell in which he died under arrangements made by the prison FLO.
119. I am impressed by the manner in which the Governor personally took the lead
in breaking the news of the man’s death to his family. I also make special
mention of the prison FLO, who, in my opinion, discharged her responsibilities
in her role with the highest standards of professionalism and sensitivity.
33
PRINCIPAL CONCLUSIONS
120. The clinical reviewer has concluded that a number of key healthcare
interventions were either omitted or not undertaken adequately and that,
consequently, the healthcare the man received at both Peterborough and
Norwich fell short of the required standards.
121. The reception health screen the man underwent at Peterborough did not
adequately assess his risk of self-harm or his history of alcohol abuse. The
assessment of his fitness to attend court the next day was not based on a
face to face interview. Although he had been placed on a Methadone based
detoxification programme, he was not given his daily dose of Methadone prior
to leaving for court because of an error on his medical chart. After his court
appearance, the man did not return to Peterborough as there were no longer
any vacancies there. Instead, he was transferred to Norwich where
Methadone was not available.
122. A full reception screen was not completed when the man arrived at Norwich.
Although it was noted that he was a drug misuser, no questions were asked of
him with regard to alcohol abuse. No urine test was undertaken because of a
shortage of testing equipment. No referral was made to the detox nurse. No
prescription was issued for either opiate or benzodiazepine detoxification. No
note was made of the last time he had received any medication to manage his
drug dependency. He was assessed as being fit for normal first night location
despite his unmanaged drug dependency and history of convulsions and self-
harm. During the evening of 11 March, the man had a further seizure, the
cause of which was unclear. No advice was sought from a doctor by the
member of the healthcare team who attended. An ambulance was requested
but did not arrive. However, he made a full and prompt recovery such that the
ambulance was no longer required. Although it was known that he was an
opiate substance user, no formal arrangements were made for him to be
observed in the aftermath of his seizure and no opiate scale was initiated.
123. The following morning, the man had another seizure and was admitted to the
healthcare centre. During the afternoon, his behaviour deteriorated. He
threatened to kill himself if he was not discharged to a wing. He spat at a
member of staff who was trying to help him calm down. Because of this
behaviour, the observation hatch in his cell door was kept for a time in the
closed position. This was not in keeping with national guidelines for the
management of prisoners subject to substance withdrawal programmes.
124. The clinical reviewer makes a number of recommendations for the
improvement of healthcare systems at both Peterborough and Norwich so that
these faults can be remedied. I argue that prisoners who are subject to
detoxification programmes should be returned to the discharging prison to
continue their prescribed detoxification regime after their court appearances. I
am concerned that Operation Safeguard is not in practice ensuring the
continuity of medical treatment. The dangers in respect of those detoxifying
from drugs need no elucidation.
34
125. I am satisfied that the response to the discovery of the man hanging was both
prompt and effective. I commend those staff who tried to save his life.
126. I am impressed by the manner in which the Governor personally took the lead
in breaking the news of the man’s death to his family. I also make special
mention of the prison FLO, who, in my opinion, discharged her responsibilities
in her role with the highest standards of professionalism and sensitivity.
35
FAMILY CONCERNS
At draft stage, the man’s family raised a number of concerns they felt had not been
adequately reflected in the draft report. My investigator therefore put their questions
in writing to the Director of Peterborough and the Governor of Norwich. I repeat
here, verbatim, the family’s questions and the responses received.
Questions to the Director of Peterborough
1. Once someone has been prescribed some medication ‘outside’ why is this
automatically stopped when someone goes into prison without even asking for
previous medical records?
Response:
When a person enters prison it is normal for some drugs to be disallowed due to the
establishment’s protocol.
2. How long do you have to be in custody before your medical records are
requested? Is there a procedure for this?
Response:
Previous medical records are sought from outside the same day unless reception
occurs on a weekend. This is standard practice.
3. Peterborough knew the man was on methadone and diazepam (he told them) and
they had put him on methadone in October anyway. Why didn’t they check this out
instead of letting him withdraw on a very reduced amount?
Response:
Due to the fact that the man had been in custody elsewhere and was unable to
maintain his methadone during that period, when he recommenced his methadone at
Peterborough it would have been unsafe to give him the amount he had taken
previously. It was therefore safer to start him on a lower dose which should have
been gradually increased up to, or close to, his normal dose. The man was on
diazepam at the time he was in Peterborough. The doctor’s entry in records dated 8
March confirms this.
4. If it was obvious that the man was withdrawing (and a number of staff mentioned
they could tell he was doing so), why wasn’t he referred to a drugs counsellor at
either prison? What sort of counselling is available at both prisons?
Response:
There is a CARATs service at Peterborough and we also have a Substance Misuse
nurse working within the prison to provide drug counselling support to prisoners.
36
The man’s records show that he was asked to attend healthcare on 10 March 2008
for an assessment with the Substance Misuse nurse but he did not attend.
The Director Peterborough of Peterborough ended his letter with the following words:
“Once again I would offer our deepest sympathy to the man’s family. I am sure that
this has been a very difficult time for them and it will no doubt take a considerable
time for the family to recover from the shock of their loss.”
Questions to the Governor of HMP Norwich
1. The man arrived at about 5.00pm. Someone from the prison phoned (his sister in
law) at about 5.30pm to tell her that he had arrived there. She got the impression
that he had asked that they ring her. If someone could ring up about his arrival, why
didn’t anyone think to ask her about his fitting and medication? Or at least find out
from her who his GP was?
Response:
The man arrived at HMP Norwich on 11 March 2008 and it is believed that a phone
call was made by the First Night Centre staff (E Wing) at his request, to his sister in
law to inform her that he was at Norwich prison and not at Peterborough. ‘Courtesy’
calls are made by First Night Centre staff on behalf of prisoners on the first night to
inform family members/relatives that the person is at Norwich. It is not normal
practice for First Night Centre staff to ask family members /relatives for further
information, particularly of a medical nature. If the information is forthcoming from
the family member, then that is written down and, if necessary, forwarded to the
medical staff. The nurse in reception had access to the man’s medical information
from Peterborough. She saw him at approximately 5.00pm and, according to the
medical information, a full reception screen was done. She recorded that he should
be seen by the doctor in the morning.
2. She (the man’s sister in law) is shocked that the man saw a locum agency doctor
who did not have any knowledge of his medical history. Why does Norwich have to
rely on agency staff? Surely a prison needs their own designated healthcare staff,
including doctors? Is there a staffing problem? What is being done to address it?
She (the man’s sister in law) is also shocked that the doctor saw him in a room
where the computer was not working. How could a proper assessment be made of
the man’s medical needs? Or at least register that this was inadequate and
schedule an urgent full assessment with relevant information?
Response:
The tender for GPs sits with the Commissioners NHS Norfolk. The tender was not
let at the time. It was re-tendered in July 2008. The Head of Healthcare has stated
that even if there had been a substantive GP they still would not have known the
man. Prison healthcare is part of the NHS and. Like the NHS, has staffing
challenges Recruitment is on-going. Hence the reason for relying on agency staff.
There is a core group of designated healthcare staff but not doctors. The man was
seen by the locum doctor. At the time, he did not have designated access to the
37
computer. However, he did record his consultation under authorised access after
seeing him. The consultation was recorded on the computer at 10.42am on 12
March.
3. The man tried to make a phone call at about 4.00pm on 12 March. His sister on
law believes this could have been to her. He was clearly frustrated by his failure to
get through. Why didn’t staff try to help him communicate with the outside? There is
no evidence of any empathy with someone who was getting increasingly wound up.
Did anyone offer him the use of an official phone free of charge?
Response:
We do not know who the man was trying to contact at approximately 4.00pm in
healthcare on 12 March 2008. It may have been his sister in law or it may have
been his girlfriend who was believed to be pregnant at the time. The HCO, also tried
the number but he was also unable to get through at the time. According to The
healthcare senior officer, who was present at the time and had spent a lot of time
with him that day, he (the man) did not state that the phone call was urgent or seem
frustrated about it.
4. The healthcare principal officer at Norwich, said that he could tell the man was
withdrawing just by looking at him. The man wanted medication and said he would
kill himself if he didn’t get any. Why then was a known self-harmer obviously
withdrawing from drugs, allowed to be shut up on his own with the hatch up? He had
clearly been labelled as a trouble maker and this seems to have dominated thinking
about how to handle him. Why was the victim of the man’s aggression (the
healthcare principal officer) allowed to remain working with him when it would have
been better to remove him from the situation?
Response:
Whilst on E Wing on 11 March 2008, the man had a fit at approximately 8.55pm and
the nurse was called. He was given diazepam orally which had been checked
against Peterborough’s drug chart. The nurse advised him to move to the healthcare
centre but he refused. He seemed fine for the rest of the night. He was seen again
at approximately 8.30am on the morning of 12 March on E wing. As previously
stated, the man was seen by the doctor that morning. According to the healthcare
principal officer, the doctor had written him up for medication but this wasn’t the
medication that the man wanted. Methadone was not prescribed at the time. He
kicked the staff office door open. The healthcare principal officer was on the phone
at the time. The man proceeded to shout at staff to get him out of healthcare and
back onto the residential unit. The healthcare senior officer was also present and he
walked him back to his cell.
Later, the healthcare principal officer went to see the man to find out what the
problem was. He informed him that healthcare was the better place for him and for
the staff to observe him. He became aggressive and in the presence of the
healthcare senior officer, he spat in the healthcare principal officer’s face and said he
was going to smash his cell. The healthcare principal officer tried to shut the cell
38
door as the man continued to kick it. They finally managed to shut the door. The
healthcare senior officer stated that it was he who put the hatch up and not the
healthcare principal officer as the man was aggressive: he had spat at a member of
staff and was heard throwing furniture around the cell. The healthcare senior officer
stated that at no point did he hear the man say he was going to kill himself. He was
not on open ACCT as he had not been flagged as a known self -harmer at the time.
It was only a few minutes later that the healthcare senior officer returned to the
man’s cell. He noted that the man had calmed down and spoke to him through the
hatch. He convinced the healthcare senior officer that he was calm and would not
throw anything at anyone out of the hatch so the hatch was left open. He was
placed on report for his action towards the healthcare principal officer.
The healthcare principal officer also contacted the police who, according to the
healthcare senior officer, interviewed the man about the incident that day. Although
the healthcare principal officer was on duty he did not have any further contact with
the man. The healthcare senior officer was on duty in the healthcare unit all day on
12 March.
5. Were medical staff aware that one of the side effects of diazepam is “fitting”?
Response:
According to the Head of Healthcare, medical staff are aware of the fact that the side
effect of diazepam withdrawal (not diazepam) is ‘fitting’. On 10 March 2008, the man
was given methadone at Peterborough. When he arrived at Norwich on the evening
of 11 March,it was not clear as to whether he had had his methadone that morning
before leaving for court as his medical chart was incomplete. He was given
diazepam orally on the evening of 11 March. On 12 March, he was prescribed
benzodiazepine detox by the doctor and he received 10mg of diazepam at
approximately 2.00pm that day.
6. If it was obvious that the man was withdrawing (and a number of staff mentioned
they could tell he was doing so), why wasn’t he referred to a drugs counsellor at
either prison? What sort of drug counselling is available at both prisons?
Response:
The man’s medical record shows that on 11 March, he was referred to the
Substance Misuse Service by the nurse in reception. According to the Head of
Healthcare, the Substance Misuse Service would normally have seen the man the
day after referral.
39
LIST OF RECOMMENDATIONS
To HMP Peterborough
Reception health screen
1. HMP Peterborough must review its policies and procedures for first reception
screening to ensure these meet national guidance. Documents which would
be useful are:
Prison Service Order (PSO) 3050 - Continuity of Healthcare for Prisoners
PSO 1025 - Communicating information about risks on escort or transfer
PSO 3550 - Clinical Services for Substance Misusers
PSO 0500 - Reception (section 4 and section 6)
Clinical Management of Drug Dependence in the adult prison setting
Particular note should be taken of the provisions of paragraph 4.4 of PSO
0500 and paragraphs 1.2 and 1.4 of PSO 1025 which set out guidance on the
use of Prisoner Escort Records. Prison healthcare staff who are responsible
for undertaking first reception screening should be appropriately qualified and
receive regular training and supervision in effective assessment of prisoners.
Fitness for court
2. HMP Peterborough should review their processes to ensure that prisoners are
seen as close to discharge as possible to confirm their fitness to attend court.
The review should include ensuring that prisoners who require medication
have received this prior to leaving and that all necessary documentation
accompanies the prisoner.
3. The current process in place for confirming a prisoner’s fitness for court must
be reviewed to ensure that where prisoners have particular healthcare issues
such as substance misuse these are taken into consideration.
Transfer of medical information
4. HMP Peterborough should ensure that the provisions of paragraph 5.3 of
Prison Service Order 3050 are followed when prisoners are transferred to
court so that they have a summary of relevant medical details available.
Where possible, this should be followed up with telephone communication
confirming current health issues.
Continuity of care
5. HMP Peterborough should review their policies in line with PSO 3050,
‘Continuity of healthcare for prisoners’ to ensure that prisoners who have not
completed opiate stabilisation are able to receive continuity of care either
through clinical hold of their accommodation or by ensuring that the receiving
prison is contacted.
40
To the Prison Service
1. The guidance in PSO 3050 covers the facility to agree a ‘clinical hold’ on
accommodation for patients whose clinical condition is such that they would
be at risk if transferred. It states at paragraph 5.5, ‘patients may need to be
placed on clinical hold’ (i.e. withheld from transfer for a period of time for
clinical reasons when indicated).
The guidance should be nationally reviewed to ensure that a clinical hold is
available for remand prisoners who have commenced substance misuse
stabilisation, to ensure they are able to return (to the discharging
establishment) if courts decide to continue custodial arrangements.
To HMP Norwich
Reception health screen
1. HMP Norwich must review the content and implementation of the policies and
procedures in use at first reception screening to ensure these meet national
guidance. Documents which would be use would be:
Prison Service Order (PSO) 3050 – Continuity of Healthcare for Prisoners
PSO 3550 – Clinical Services for Substance Misusers
PSO 0500 – Reception (section 4 and section 6)
Clinical Management of Drug Dependence in the adult prison setting
(published in November 2006).
In particular, policies regarding recognition, management and stabilisation of
prisoners who are receiving Methadone substitution and benzodiazepam
detoxification should be reviewed and implemented.
2. First reception processes should be audited regularly for quality assurance
and to confirm full implementation.
3. Prison healthcare staff who are responsible for undertaking first reception
screening should be appropriately qualified and receive regular training and
supervision in effective assessment of prisoners.
4. Access to a medical practitioner should be available to all prisoners who
require to be seen on the day of their arrival. This might be delivered by
reviewing current surgery hours to ensure that cover is available in the
afternoon to see all prisoners who require to see a doctor during normal
primary care hours of 8.30am to 6.00pm.
Managing medical emergency events
41
5. HMP Norwich should put into place protocols and care pathways for managing
emergency medical events. This should include the requirement for requesting
external medical assistance in acute medical events such as unexplained
convulsions. Healthcare staff within normal cell location should receive regular
training and supervision in the emergency assessment and treatment of
prisoners who present with acute medical events. Staff should receive training
in the management of prisoners at risk of opiate withdrawal which includes the
use of opiate withdrawal scales for monitoring their condition.
Calling an ambulance
6. The Governor should review his contingency plans for calling an ambulance to
ensure that effective drills and procedures are put in place and rehearsed by
control room and other key staff.
Management of medicines
7. Healthcare staff should familiarise themselves with medicines management to
ensure that they administer medication in line with professional legal
requirements.
Record keeping
8. HMP Norwich should have in place both protocols and training available to
staff to ensure that record keeping is standardised and includes all relevant
information including plans of care management and patients’ choices with
regard to health intervention.
9. HMP Norwich should review its policies and audit the successful
implementation of medical records systems to ensure that they meet the
current national requirements of Records Management – NHS Code of
Practice (Department of Health, published April 2006)
Clinical assessment
10. Clinical assessment of patients with substance misuse issues should follow
national guidance set out in Clinical Management of Drug Dependence in the
Adult Prison Setting published by the Department of Health in November
2006. This will require a review of the current (local) policy which was
published in May 2006 and has not been reviewed to date. An interim review
of policy must be undertaken and an implementation plan put in place as a
matter of urgency and should reflect the current situation that HMP Norwich
does not currently undertake (opiate) substitution prescribing.
11. Prisoners currently receive the majority of their care within normal location
(i.e. on a wing). Consideration must be given to ensure that primary care
within normal location is sufficiently resourced in terms of environment and
staffing to provide a safe service.
Detoxification medication management
42
12. Prescribing management for substance misusers should follow national
guidance set out in Clinical Management of Drug Dependence ion the Adult
Prison Setting. This will require a review of the local policy which has not
been updated since May 2006. Protocols should be available in all clinical
areas and should be part of prescribers’ training and induction.
Closure of observation hatches
13. HMP Norwich healthcare policy and protocol for management of prisoners
with substance mis-use should reflect national guidelines with regard to the
closure of observation hatches for prisoners receiving substance withdrawal
management. This can be found in the Clinical Management of Drug
Dependence in the Adult Prison Setting.
14. HMP Norwich healthcare staff and prison officers (working in the healthcare
centre) should receive training on the management of challenging behaviour
in prisoners with substance misuse issues.
Commendations
1. I commend those staff who tried to save the man’s life after he was found
hanging.
2. I am impressed by the manner in which the Governor personally took the lead
in breaking the news of the man’s death to his family. I also make special
mention of the prison FLO, who, in my opinion, discharged her responsibilities
in her role with the highest standards of professionalism and sensitivity. I
commend both of them.
At consultation stage, the Prison Service accepted these recommendations.
43