Individual at Bedford

Investigation into the circumstances surrounding the
death of a man at HMP Bedford
in April 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2009
This is the report of an investigation into the circumstances of the death of a
man in April 2007. At 1.30pm that afternoon, he was found hanging in his cell
at HMP Bedford by his cell mate. Cardio pulmonary resuscitation was carried
out but at 2.04pm he was pronounced dead.
I would like to offer this public expression of condolences to the man’s family
and friends on their loss. A key objective of all my investigations is to ensure
the bereaved family has the opportunity to raise any concerns and contribute
to my inquiries. Initially, his family conveyed their concerns through their
solicitor, but, eventually, in November 2007 one of my family liaison officers
and the investigator met the man’s parents and sister and they raised a
number of additional matters. It is regrettable that there was a delay in
meeting the family. I hope my investigation begins to offer answers to these
questions. I regret the delay in the completion of this report.
The investigation was led by one of my investigators, who was assisted by a
former colleague. A clinical review was conducted by the Lead General
Practitioner at HMP Chelmsford, and I am grateful for his assistance. I would
also like to thank staff at HMP Wormwood Scrubs and HMP Bedford for their
co-operation with this investigation.
The man was a long-term drug user who was initially remanded to HMP
Wormwood Scrubs where he was placed on a methadone maintenance
prescription. Following a routine court appearance, he was “locked out” of
HMP Wormwood Scrubs due to population pressures and spent the night in
police custody. The next day, he was taken to HMP Bedford where
methadone is not prescribed for drug users. Four days later, he hanged
himself. Although there can be no certainty in these matters, it is very hard to
believe that these facts are not related.
Operation Safeguard came into effect in 2006 and is used by the Prison
Service, police, courts and escort contractors to manage the shortage of
prison places. I am continuing to monitor its implementation with concern.
The man’s death, and another to have occurred in April 2008, share similar
features in that both had the clinical management of their drug problem
disrupted as a result of being unable to return to the discharging prison.
My report contains a number of recommendations concerning clinical care
and procedures. One further recommendation, plus significant textual
amendments and additions, have been added after consultation on the first
draft of this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman October
2009
CONTENTS
Summary 4
The investigation process 5
HMP Bedford and HMP Wormwood Scrubs 7
Key findings 9
Issues 20
Recommendations 26
SUMMARY
Following arrest by the police, the man was remanded to HMP Wormwood
Scrubs on 15 March 2007. He was a long-term drug user who had been in
Wormwood Scrubs, mainly on remand, on a number of occasions and was
known to staff there. He was located on the Conibeere Unit, a dedicated wing
for drug users, and started on a methadone maintenance prescription. On 22
March, he returned to court and was further remanded until 12 April. He
returned to Wormwood Scrubs and continued on his methadone
maintenance.
On 12 April, the man was one of three prisoners to go to court from the
Conibeere Unit. He appeared at the magistrates’ court and was remanded
until 19 April. Population pressures throughout the prison estate meant that
he was unable to return to Wormwood Scrubs. (In such circumstances,
prisoners are taken by the escort contractors to the nearest available space at
a police station. This is known as Operation Safeguard.) He was taken to the
police station where he was given medication overnight to help with his
withdrawal symptoms.
The following morning, the man was taken to HMP Bedford, the nearest local
prison with available space within the jurisdiction of the escorting contractors.
He arrived just after 3.00pm. During the reception medical screen, and
subsequent appointment with the prison General Practitioner (GP), the man
explained that he was a drug user. He was assessed as suitable for a
withdrawal programme using lofexidine and other symptomatic relieving
medication. This was started the following day. He was also suffering from
an ulcer but was not given the medication he had been prescribed in
Wormwood Scrubs.
The man was placed in C wing. During the early hours of 16 April, his cell
mate pressed the cell bell complaining that he could not cope with being in a
cell with the man because he was suffering badly from detoxification
symptoms. Staff moved the other prisoner to another cell.
In the morning, after complaining of vomiting, the man again saw the prison
GP who changed some of his medication. Later that afternoon, he moved to
cell C3-10. His new cell mate told my investigator they stayed awake talking
most of the night as the man was unable to sleep due to withdrawing. The
following morning (17 April), the man told a member of healthcare that he was
feeling better. Over the lunchtime period, the cellmate fell asleep in the cell.
He awoke to discover the man slumped on the floor and with a ligature tied
around his neck. He immediately cut the ligature before ringing the cell bell
and kicking the door to attract urgent attention. Within minutes, staff entered
the cell and began cardio pulmonary resuscitation (CPR). At 2.04pm, the
man was pronounced dead.
After the man’s death, the prison complied with the required procedures. Staff
had the opportunity to use the services of the care and welfare team and
prisoners subject to Assessment, Care in Custody and Teamwork (ACCT)
monitoring (used to support and monitor those thought to be at risk of self
harm) were checked. After some initial difficulty, the prison managed to
contact his family the next day.
I make a number of recommendations relating to clinical care and procedures.
THE INVESTIGATION PROCESS
1. My former colleague conducted a preliminary visit to HMP Bedford on
24 April to open up the investigation. She also visited the cell where
the man died. Subsequently, all the relevant documentation was
reviewed and a chronology of events established. Feedback about the
findings of the investigation was given to the then Governor, on a
regular basis.
2. Notices were issued to staff and prisoners telling them of the
investigation and offering the opportunity to speak with my colleagues.
No one came forward as a result.
3. My investigators met representatives of the local branch of the Prison
Officers’ Association (POA) and the Independent Monitoring Board
(IMB). No specific concerns were expressed. The man’s last
probation officer and the solicitor who represented him at his final court
appearance were also contacted for background information.
4. Given that the man had spent the majority of his time in custody in the
Conibeere Unit in HMP Wormwood Scrubs, my colleagues visited the
unit and spoke informally with a number of staff. They also visited the
Population Management Section (PMS) at Prison Service
Headquarters to discuss the daily logistics of Operation Safeguard.
(On a daily basis, PMS assess how many prison discharges there were
in London and notify the contractor (SERCO). The contractor would fill
these spaces and then any number over and above would have to go
to other available prisons or available police cells.) Feedback about his
death with regard to Operation Safeguard was given to Safer Custody
Group over the telephone during the course of the investigation. (Safer
Custody Group is the policy unit within Prison Service Headquarters
that issues instructions and guidance to prisons on the management
and prevention of suicide and self-harm.)
5. Thirteen members of staff, both discipline and healthcare, were
interviewed at Bedford by my investigator and former colleague. The
man’s cellmate at the time of his death was also interviewed. (The
cellmate has since been released from custody and my investigator
has been unable to make contact with him at his discharge address.
Consequently, he has not had sight of the transcript of his interview.)
His first cellmate was released from Bedford within days of his death
and did not provide a discharge address so could not be contacted.
The prisoner in the neighbouring cell was unable to provide any
information for the investigation.
6. The Lead GP at HMP and YOI Chelmsford and Prison Service Eastern
Area, Clinical Advisor for the Integrated Drug Treatment System,
undertook a clinical review of the healthcare provided for the man. The
clinical reviewer was given copies of all the medical transcripts. He
also visited Bedford and spoke to two members of staff, including the
prison GP.
7. Shortly after the man’s death, solicitors appointed by his family
contacted my office requesting that all contact be made through them
rather than directly with the family. My colleagues complied with this
request, but a subsequent miscommunication between my office and
the solicitor meant that a meeting with the family was unfortunately
delayed. This caused the family great distress. I regret and apologise
for this. However, this was remedied and the investigators met the
man’s parents and sister late in November 2007 when they gave an
overview of the investigation.
8. The man’s family had some additional questions about his medication
at HMP Bedford. My investigator relayed these to the clinical reviewer
and he subsequently elaborated on these issues in his clinical review.
9. A draft version of this report was sent to the Prison Service. An action
plan was provided in response. Paragraph 65 has been elaborated to
include further details regarding the discovery of the man.
10. The man’s family were sent a copy of the draft version of this report.
His mother, father and sister responded separately in writing to the
report. Having considered their views, I have added a further
recommendation to which the Prison Service have also responded. In
addition, his family felt that the commendation of staff involved in
attempting to resuscitate the man was insensitive. I have respected
their comments and removed it from the report.
11. The Primary Care Trust, through their solicitors, made a number of
comments regarding the draft report. No changes were made as a
result of their comments.
12. Following the issuing of the revised draft report, in December 2008, a
meeting took place between the man’s family and their solicitors and
my investigator and other staff members including the deputy
Ombudsman. Following the meeting my investigator completed a
number of additional enquiries. These were:-
(cid:127) My investigator wrote to the Governor of Bedford for further
details of the drug policy.
(cid:127) Additional material has been included in the final report regarding
the background information about Bedford and drug policy.
(cid:127) My investigator asked the Clinical substance misuse advisor,
Offender Health, to review the man’s case and provide a report.
(cid:127) A statement has been provided by the Deputy Head of the
Population Management Section.
(cid:127) Some changes to the text at the request of the man’s mother.
HMP BEDFORD AND HMP WORMWOOD SCRUBS
HMP Bedford
13. HMP Bedford is a small, city centre local prison. In an unannounced
short follow-up inspection report in April 2006, the HM Chief Inspector
of Prisons, described Bedford as “a fundamentally safe prison”. She
concluded, “this is a prison that has been able to work sensibly and
remarkably effectively given the challenging population and the
constraints of its old buildings.”
14. However, the HM Chief Inspector of Prisons report went on to say:
“… we have drawn attention to some shortcomings in the area
of drugs detoxification, and arrangements to maintain drug
support for those who are not in custody for lengthy periods.
Both of these areas are now behind contemporary practice
elsewhere.”
On page 18, the HM Chief Inspector of Prisons wrote:
“We found that clinical management of substance users was
poor or nonexistent. Neither subutex nor methadone was used.
Men who arrived at the prison on a maintenance prescription of
methadone were not able to continue with it, but were instead
only given symptomatic relief on their first night in custody, and
were then offered a fourteen day britlofex detoxification
programme.”
15. The HM Chief Inspector of Prisons recommended:
“The clinical management of substance users should be
urgently reviewed in conjunction with the national prison health
clinical substance use lead. Maintenance prescribing,
adequate first-night medications, and appropriate detoxification
regimes to meet the needs of prisoners, should all be
introduced by the prison.”
16. The action plan by Bedford in response to the recommendation stated
that by 31 March 2007:
“A new Head of Healthcare and doctor, who specialises in
substance misuse, have been appointed. Six weekly meetings
are now held to review our approach to clinical substance
misuse policy. Bedford has not received funding for the
Integrated Drug Treatment Systems (IDTS), but we are
committed to improving provisions within current resources.”
17. By letter, my investigator asked the Governor about the policy for
prisoners arriving by unplanned transfer from a prison with IDTS. He
stated:
“At the time of the man’s death, prisoners who arrived by
unplanned transfer, and who were on methadone maintenance,
were converted to the local opiates policy, which at the time was
the prescription of Lofexidine.”
18. The Integrated Drug Treatment Systems is a national mandatory
programme for prisons. The National Treatment Agency (NTA)
determines the programme for the roll out of the IDTS across the
prison estate. IDTS aims to not only increase the volume and quality of
treatment available to prisoners, with particular emphasis on early
custody, but also to improve integration between clinical and CARAT
(Counselling, Assessment Referral Advice and Throughcare) Services
and to reinforce continuity of care from the community into prison,
between prisons, and on release into the community.
19. HMP Bedford was in the third roll of IDTS and funding made available
from April 2009. The criteria used for the selection of the IDTS Third
Wave prisons were a combination of:
(cid:127) Priorities for clinical treatment need in those prison not yet
receiving additional funding;
(cid:127) Those trainer prisons taking prisoners from these newly
identified local prisons;
(cid:127) Those non-IDTS funded local prisons in which suicides have
occurred in the last financial years;
(cid:127) Prisons serving localities with a prevalence of drug-related
deaths greater than 7/100,000 population.
(IDTS Announcement letter, April 2008)
20. There have been five apparent self-inflicted deaths at HMP Bedford
between December 2004 and this man’s death in April 2007. Although
the circumstances of these deaths are not similar, this investigation
found some common features with two of my previous reports
regarding the use of emergency equipment. Although these were not
found to have contributed to the deaths, this report makes a number of
similar recommendations in this area.
21. A further inspection of HMP Bedford took place in February 2009. The
findings of this inspection have not been included in this report since it
took place nearly two years after the death of this man.
HMP Wormwood Scrubs
22. HMP Wormwood Scrubs is a category B local prison. It has one
dedicated wing, for drug users, Conibeere Unit (CBU), which was
introduced in 2004. The unit is staffed by both clinical and discipline
staff and holds a maximum of 46 prisoners. A number of detoxification
options are available based on individual need including a methadone
maintenance programme.
KEY FINDINGS
23. The man was arrested at 11.06am on 14 March 2007and taken to the
police station. A routine risk assessment form was completed by a
police officer on the basis of information provided by him. He
described himself as suffering from depression, being a heroin addict
and having an ulcer. It was recorded that he was taking methadone
and “ameprazol” (sic). (There are a number of spelling mistakes of
omeprazole throughout his records. Each time, the spelling used by
the author has been included in this report). He was offered the
chance to see a drug referral worker which he said he was interested in
doing. The man was asked if he had ever tried to harm himself to
which the officer wrote “no”. He told the officer that he had an anti-
social personality disorder. According to the officer, he appeared
under the influence of drugs and he concluded that he was “a risk”.
24. At 2.12pm, the man was seen by the Forensic Medical Examiner
(FME), a doctor who provides services to the police service. At that
time the FME concluded that hel was fit to be detained but not fit for
interview. He wrote:
”heroin addict (IV) use, PH peptic ulcer, depression and self-
harm, appeared co-operative and orientated, no recent self-
harm, ½ hour observation, will be fit for interview at 6pm, given
LOSEC 40mg x 1 and DHC [dihydrocodeine] 30mg x 2.”
25. The same FME saw the man at 6.00pm, identified him as fit for
interview, and again prescribed 60mg DHC. In addition, the FME
recorded that the man was Hepatitis C positive and a self-harmer, and
that the half hourly observations should be continued. At 9.29pm, he
was charged with burglary of a non-dwelling property between 7/8
February 2007.
26. In the early hours of 15 March, at 1.30am, the man saw another FME
who observed that he was withdrawing from opiates. He prescribed
60mg DHC and 7.5mg of zopiclone (usually prescribed for insomnia in
withdrawing drug users). There was no mention of self-harm.
27. The man was taken to the magistrates’ court later that morning and
was remanded into custody until 22 March. The Prisoner Escort Form
(PER), designed to communicate important information between the
various criminal justice agencies, indicated that his risk categories were
“medical condition, escape risk and drugs/alcohol”. In a further section
concerning risk issues, it stated “heroin addict, hep c, has escaped
lawful custody”. The form mentions that it ”took 6 policeman to put him
on the van at the police station, violent and mouthy.”
28. The PER recorded that the man left the court at 5.55pm. Neither the
escort staff nor receiving prison staff completed the PER to show that
he was handed over to staff at Wormwood Scrubs or at what time.
Upon his arrival, he went through the reception process. This included
staff completing the core record (form F2050) which asks basic
questions about age, religion and other such information. The form
also requires the prisoner to provide the name and address of his next
of kin but he did not do so and gave his solicitors as the contact for an
emergency.
29. A cell sharing risk assessment (CSRA) was completed. The man was
noted to be dependent on drugs. In response to the question as to
whether the prisoner has an open 2052SH (a system of monitoring
those at risk of self-harm or suicide), the author wrote “no” but ticked
“yes” to the question asking if there is evidence of the prisoner having a
previous 2052SH. All the answers, bar the last, indicate that he was
the source of this information. (It is not known if this was a mistake on
the author’s part and if the final answer was also provided by the man.
Staff would not routinely have known if a new prisoner had previously
been on suicide support and monitoring arrangements. When he had
previously been in Wormwood Scrubs in December 2006, he had not
been on any suicide monitoring.)
30. In response to further questions, the man said he did not have any
concerns about sharing a cell but described himself as someone who
gets “angry/frustrated quickly”. The assessor concluded that the man
was of low risk of harm to others and was suitable for multi-cell
location. Section 3 of the CSRA was completed by a nurse who
concluded that he was of medium risk to others. This indicated that
there was “no immediate risk but situation will need to be reviewed
regularly”. In response to the question ”following the self-harm
assessment have any concerns been raised?” the nurse ticked “no”.
31. These answers would have been informed by the First Reception
Health Screen (FRHS) that was completed by the same nurse. The
man said that he had seen a doctor recently for a perforated ulcer and
was taking omeprazole 20mg daily and methadone. He went on to
give details of his drug use and took a urine test that proved positive for
heroin, methadone, benzodiazepines, cocaine/crack and cannabis.
32. Question 10 of the FRHS asked, “Have you ever tried to harm
yourself?” to which the author wrote “yes (in prison) DHS (sic) (Dec
2006).” (During a visit to Wormwood Scrubs my investigators checked
the man’s old records from 1-7 December 2006. There was no record
of an incident of self-harm during this time. This suggests that any
attempt by him to harm himself was not known by staff at the time,
hence not recorded.) Question 11 asked, “For some people coming
into prison can be difficult, and a few find it so hard that they may
consider harming themselves. Do you feel like that?” Neither “yes” nor
“no” was ticked. The author was then asked to “record your impression
of the prisoner’s behaviour and mental state” and wrote ”appears
stable at present”. It was concluded that he needed to see a doctor
due to his physical health and substance abuse.
33. The man’s prescription chart indicates that at 10.20pm he received a
once only dose of zoplicone (7.5mg), buscopan (20mg), loperamide
(2mg) and metoclopromide (10mg). There is a reference number for
Primecare and the nurse’s signature. This suggests that the nurse
contacted the out of hours doctor and, following an assessment, was
granted permission to prescribe these drugs which are routinely given
at Wormwood Scrubs for the difficulties associated with withdrawal
from drugs (insomnia, abdominal cramps, diarrhoea and vomiting).
34. In the man’s medical records there are three separate entries on 16
March. It is not possible to decipher the corresponding signatures.
The first one indicates that he was seen in the First Night Centre and
gives brief details regarding his ulcer which at that point was described
as asymptomatic. The second is an in-depth history of his medical
needs and his 15 year drug history. It recorded that he had had no
overdoses, but six fits during withdrawal from substances in the past. It
went on to say that there have been no suicide attempts and no
thoughts about self-harm or suicide. However, the author has then
recorded: ”then said he tried to hang himself and harm himself when
withdrawing – last time in December.” The author has concluded:
“methadone titration and maintenance, symptomatic relief and
carbamazepine in view of previous seizures.” (Carbamazepine is
routinely provided for prisoners undergoing a detoxification at
Wormwood Scrubs, for 14 days initially. However, there is no
corresponding prescription chart in the man’s records and therefore it is
not known if he was actually prescribed carbamazepine at Wormwood
Scrubs.)
35. The man was located in the Conibeere Unit, Wormwood Scrubs’ drug
wing and started on a methadone regime. A ‘Current Admission and
Research Form’ was completed and he was asked about suicide
indicators. He answered yes to previous attempts, by “hanging [and
something illegible] but is not expressing suicidal ideation at that time
or does he have a plan made.” Under history of self-harm a tick was
placed against ‘no’ (when it should be ‘yes’ given his previous answer).
36. After seven days, the man went onto a methadone maintenance
programme of 50mg a day. In his medical records, there are almost
daily notes by the nurses who administer methadone in which they
indicated no concerns and that he appeared stable.
37. On 22 March, the man returned to the magistrates’ court for a routine
court appearance. He was remanded until 12 April and returned to
Wormwood Scrubs.
38. My investigators visited Wormwood Scrubs and spoke with the
Substance Misuse Service Team Leader. The man was known to staff
there because of previous remands. The team leader described him
as usually polite and quiet and that he liked to be by himself. She said
that he could be difficult when he first came in but would calm down
once he began his medication. This was supported by prison records
from December 2006 which showed that he spent two days (during a
stay of seven days at Wormwood Scrubs) in the segregation unit after
throwing water at a nurse.
39. On 12 April 2007, the man returned to the magistrates’ court. His PER
indicated that he had a problem with drugs and in the section “further
information about risk” was written: ”not to be given opiate based
medication on methadone maintenance.” He appeared in court and
was further remanded until 19 April.
40. The man had expected to returned to Wormwood Scrubs, but during
the afternoon that prison and a number of others had to “lock out”
prisoners due to the swelling prison population. He was one of three
prisoners who had left Wormwood Scrubs that morning to go to court
who was locked out and was subject to Operation Safeguard.
(Operation Safeguard came into effect on 12 October 2006. Under
these procedures, police cells are used to hold prisoners from court
who cannot be placed in prison accommodation because of
overcrowding. In these circumstances, a prisoner is taken to the
nearest police station with available space. This may mean travelling
outside the contracted area of the escorting service. Under these
measures, where prisoners are placed in police cells, it is intended that
they should spend only one night there and be returned to their
discharging prison the next day. The procedures are set out in Prison
Service Instruction 30/2006.)
41. The man was taken to the local police station where he spent the night.
The police custody risk assessment sheet indicates that he told staff he
had a stomach ulcer and was a heroin addict for which he was
receiving methadone and “amerpail x tablets – evening” (sic). In
response to the question, ”Have you ever tried to harm yourself?” the
assessor ticked “no”. He was assessed as a risk. No further
explanation or details were given.
42. The PER for 13 April outlines drugs, escape risk and medical condition
as risk categories. Under the section “Further information about risk”
the author wrote: ”D/P states he suffers from a stomach ulcer and on
methadone. Prescribed and given 2 x 30mg Dihydrocodeine and 1 x
5mg Diazepam @ 06.35 hrs 13/4/07.” Part B of the PER, which gives
a record of events, indicates that the man was given further medication
at 12.30 pm. The PER suggests that the intended journey was for him
to go from the police station back to Wormwood Scrubs. However, he
left the police station at 2.47 pm and arrived at HMP Bedford at 3.09
pm.
43. The police station comes under the jurisdiction of the GSL East escort
service. Although the man was taken to the police station by Serco,
who operate the escort service between Wormwood Scrubs and the
magistrates’ Court, he could only have been transferred from there to a
prison within the responsibility of GSL East. In addition, due to the
demand on prison spaces within the London area, once prisoners had
been transferred out of the area it was not desirable to return a
prisoner back into the area with high demand during Operation
Safeguard.
44. The man was one of 26 new receptions who arrived at Bedford on 13
April, making it a very busy day. All new arrivals have to be inducted
by discipline staff and see both a nurse and a doctor. The First Night
Centre, on the lower floor of C wing, holds only 16 prisoners and so
some prisoners are located directly onto the upper landings.
45. Upon his reception at Bedford, a Cell Sharing Risk Assessment
(CSRA) was completed. The man said that he had abused drugs, but
in response to being asked if he was currently dependent told the
assessor “no”. When asked if he was on an open F2052SH or if there
was any evidence of a previous F2052SH, he also responded “no”. He
also said he had no concerns about sharing a cell and described
himself as someone who did not get angry/frustrated quickly. The
assessor concluded that he was at low risk of harm to others and
suitable for multi-cell location. He was located in cell C3-007 which he
shared with another prisoner.
46. The same officer conducted a first night interview with the man. He
asked him whether it was his first time in custody and if he had any
concerns about being in prison. He also asked if he had ever
committed an act of self-harm/attempted suicide and if he felt at risk of
self-harm. He answered “no” to all four questions.
47. A nurse completed section 3 of the CSRA. The only box she ticked
was that the man was a medium risk, which is described as “no
immediate risk but situation will need to be reviewed regularly”. In
interview, the nurse said she had identified him as a medium risk
because he was withdrawing from drugs.
48. Bedford operates a computerised healthcare system and entries are
completed electronically at the time of seeing the patient. A second
nurse, who completed the records at 4.12pm was very new in post, and
in interview she could not recall the man. She said that she was still
being supervised in reception because she was so new. Although her
colleague was there, the second nurse carried out the interview. She
recorded that the man was “quiet and calm and his skin appearance
was healthy”. He said he was concerned about detoxing and was
receiving omeptrzole (sic) 20mg daily and methadone 50mgs daily.
The second nurse recorded that health information had been received
from an outside source indicating that his medical records would have
been with him. In response to being asked if he “had harmed himself
inside or outside of prison?” he had answered “no”. He said he had
received treatment from a psychiatrist outside prison and that he had
been diagnosed with an anti-social personality disorder. It was
recorded that he “said that he was anxious about giving up
methadone,” and had been referred to the doctor.
49. The man was seen by the prison GP who prescribed a “standard 14
day opiate detoxification regime using Lofexidine”. The prescription
chart for that day indicates that the prison GP prescribed a once only
prescription of diclofenac, buscopan and Nitol. This is in line with
Bedford’s policy and would have been given to him by one of the
reception nurses that evening until the lofexidine programme started
the day after.
50. In interview, the prison GP described the consultation with the man:
“He was very upset and aggressive then because he was told
he couldn’t have his methadone and was anticipating cold
turkey. That made for the consultation starting off on a
confrontational basis because I was having to tell him he could
not have what he was expecting to have. The problem we’ve
got here is that identifying those people who have underlying
strong suicidal ideation is rendered much more difficult under
such circumstances. All that one can see is expressed anger.
And in fact, when I saw him on the Monday before he killed
himself, he was still very angry. I told him I was sorry I could not
prescribe him what he was asking for.
“I had the IMR from Wormwood Scrubs so I knew the situation
there. He had been on 120mls of methadone outside, it had
been reduced to 50ml and then he’d gone to court, then been
locked out of Wormwood Scrubs. He’d stayed overnight in
police custody. Now in police [custody] the forensic medical
examiners, generally speaking, hand out dihydrocodeine and
diazepam as apparent standard practice to people who are
opiate dependent. They use dihydrocodeine because it’s a
short-acting drug, not even a controlled drug but it does blunt
withdrawal, and they give diazepam, and that’s quite helpful.
But there again, he comes here and he says: ‘Why can’t you
give me dihydrocodeine? They could in the police station!’ and I
have to say: ‘I can’t because the protocol says I can’t, this is the
way we’re supposed to do things here.’ So the issue here is a
man who has a very reasonable expectation, and I am really
struggling to answer the questions that he has.
“It was fairly tense but it was basically me trying to sell
detoxification to him. Unfortunately we have to focus on this
issue of the opiate dependent person going to have a detox
whether he likes it or not, and having to persuade him that it will
be okay, even though it might not be.”
51. In addition, the prison GP was asked whether he spoke specifically
about self-harm and suicide with the man:
“The problem is that when they kick-off, and get angry, if you
then ask them whether they are going to kill themselves, they’ll
likely say ‘Well, I don’t know what I’ll do!’ and it’s then very
difficult to differentiate those people that you genuinely need to
watch from those people who are just angry because they have
been thwarted, but do not intend to kill themselves. We cannot
open an ACCT document on every single person who comes in
with substance misuse and is going through opiate withdrawal. It
would be very difficult to maintain that level of surveillance on
that number of prisoners. So yes, in retrospect an ACCT
document wasn’t opened on this man, the question of suicidal
potential I don’t think was addressed as well it should have
been, and I look at myself and blame myself. I mean, I generally
tend to have a conversation around suicidal ideation if I possibly
can. It wasn’t documented in this case, and I can’t recall
absolutely whether we did touch on it in consultation on Friday
night … On the Friday we may have touched upon it, as my
usual practice is to ask about self-harm and I usually record that
in notes. On this occasion it wasn’t recorded, so I might not
have asked the question. Alternatively I might have asked it and
not actually recorded it, I can’t recall, whether I did or not, in this
particular circumstance.”
52. The prison GP was asked about the added complication of the man’s
stomach ulcer:
“I have to say that was a concern to me because this boxed me
into a corner. One of the drugs you have available to give him,
to stop pain in the muscles, you can’t give because he’s got this
history of a bleeding stomach ulcer. So you are in effect saying:
‘We’ll punish you even more now, by saying you can’t have this
drug, because you’ve got a history of bleeding stomach ulcer.’
So I actually prescribed him diclofenac which is not something
I’d really like to have done. Then he came to see me on
Monday and said that he was vomiting and there were streaks of
blood in it, so I had to stop the Diclofenac. So that meant I was
then reducing even what he was getting.”
53. In line with Bedford’s policy, the detoxification prescription was written
up to start the following day, Saturday 14 April. The routine
prescription was for diclofenac, buscopan, diphenhydramine
hydrochloride, all for seven days, and lofexidine for 14 days. On that
Saturday, the man’s blood pressure was taken twice although the times
were not recorded. (The protocol states that this must first be before,
and then half an hour after, the first dosage of lofexidine.) No specialist
detoxification nurses worked at Bedford during weekends, although all
nursing staff are trained to work with prisoners undergoing a
detoxification and are familiar with the protocol. On the first day,
lofexidine has to be seen to be taken by the prisoner and then given
daily in possession.
54. In interview, a pharmaceutical technician recalled speaking with the
man on 15 April as she was giving out medication that day. She said
that he had asked her about methadone. She had explained that no
detoxification nurses were available at the weekends and that he
should ask to see the doctor.
55. The observation book on 16 April shows: ”during the night [the man’s
cellmate] pushed his cell bell stating that his cell mate was detoxing
and doing his head in. He requested to move cells before he done
something stupid. He has now been located in cell C1-2 overnight.” In
interview, an officer recalled answering the cell bell and speaking with
the cellmate who said that the man was keeping him awake with his
detoxification symptoms. Unable to recall the exact time, he thought it
was in the early hours of the morning. The cellmate was then located to
another cell. The officer said that the man seemed fine and had no
concerns about him. (My investigators were unable to speak to the
cellmate because he had been released from custody.)
56. As part of the induction process, the man was visited by a Counselling
Advice Referral and Throughcare (CARAT) drug service worker on 16
April. Engaging with the CARAT team is entirely voluntary. He wrote:
”declined induction – seen in cell.” Investigators spoke to the CARAT’s
worker who was unable to recall anything specific about the man. He
explained that it was not unusual for prisoners to decline to see a
CARAT worker.
57. On 16 April, the man asked to see the doctor during morning
medication and an appointment was booked at 8.17am. He saw the
prison GP at 3.27pm and the notes read: “c/o vomiting and has brought
up streaks of blood. Stop diclofenac, start omeprazole 20mg nocte and
paracetamol. Not happy at having britlofex detox. Adv we have no
choice in the matter.” The prescription chart indicates that he was
given a five day dose of prochlorperazine and seven days paracetamol.
In interview, the prison GP said about this consultation that it “was
even more confrontational (than Friday’s) about medication, and at the
end he left abruptly before I had a chance to do anything more.”
58. At 3.30 pm, the man moved into a cell with another cellmate. A
number of documents should be completed when a prisoner moves
cells but none was done so in this man’s case. Part of the process is
to check the risk assessment of each prisoner to see if they are
suitable to share but there is no evidence to indicate that this was
done. Although the man and the new cellmate were deemed suitable
to share, my investigators were unable to find out which officer had
sanctioned the move.
59. At interview, the new cellmate said he was aware that the previous
cellmate was finding it difficult being in a cell with the man while he was
detoxing. The new cellmate said that he was willing to share with the
man because he was not worried about losing sleep as he had been
through the same experience himself at Bedford a few months earlier.
60. Given the man’s withdrawal symptoms and insomnia, the new cellmate
said that he and the man were awake much of the night talking. He
said the man told him about his long standing drug addiction and all the
associated problems of homelessness and prison. The man had said
he had felt quite at home at Wormwood Scrubs and that coming to
Bedford was the worse thing that could have happened to him. He
complained about the prison GP and the lofedixine programme.
61. The new cellmate said they spoke about suicide and the man had
admitted to experimenting with ligatures. He said he had described
tying a noose around his neck and then stopping at the last minute.
From the new cellmates’ account, he had said that if he could face
doing that, then he could cope with anything that life threw at him. The
new cellmate shared his own experiences with him and said he was
very candid about how he had previously felt suicidal as well. He said
the man told him that he had found it very positive speaking with him
and was encouraged that the new cellmate had become drug-free.
62. The following morning, the pharmaceutical technician saw the man
again while giving out medication. He told her he had seen the doctor
the day before and had been given some anti-nausea medication and
was feeling much better. The prescription chart shows he was issued
with in-possession omeprazole 20mg on 17 April, having been
prescribed it by the prison GP on 16 April. The pharmaceutical
technician was asked in interview how the man had presented during
her encounters with him. She said that he was polite and never gave
her any indication he would harm himself. She commented that he did
not look especially ill and could walk and talk without difficulty.
63. The substance misuse nurse specialist, and one of two specific
detoxification nurses at Bedford, spoke with my investigators. She
explained that there are two part-time detoxification nurses who
between them provide full-time cover during weekdays. In addition,
they have to carry out other duties. The week beginning 16 April was
unusual in that both the substance misuse nurse specialist and her
colleague were not working that Monday. One of their usual duties on
Mondays is to see all the prisoners who have started their
detoxification over the weekend (the man would have been on their
list). This consultation would have included a questionnaire from which
a care plan would have been drawn up. Instead, they had scheduled
to see all the prisoners on Tuesday afternoon. In their absence, he
would have been able to request to see a nurse or doctor if required.
64. During the morning of 17 April, the man’s cellmate went to the gym,
leaving him alone in the cell. They then went to the exercise yard
together where the man spent the time sitting on a bench. Later that
morning, they collected their lunch and returned to the cell. The
cellmate said in interview that, after having lunch, he was extremely
tired having stayed awake all night talking with the man. He recalled
the man asking him if he minded the television being turned off and
then falling into a very deep sleep. When he awoke he saw him sitting
on the floor underneath the window. Initially, he did not notice anything
unusual and started to speak to the man. He then noticed that he had
a ligature round his neck and attached to the bars of the window. The
cellmate used his plastic knife from lunch to cut the ligature. The man
fell to the side and he tried to find a pulse but was unable to do so. He
said that he was very cold to touch. At this point, he rang the cell bell.
65. An officer was passing through C wing at approx 1.30 pm. He saw the
red emergency light on above the door of cell C3-10 and heard
someone kicking the door. He immediately went to the door and
opened the flap. In interview, the officer said he saw the cellmate first
at the flap and only saw the man slumped on the floor in a sitting
position when the cellmate said that his ‘pad mate had tried to kill
himself’. Upon seeing the man, the officer called for medical
attendance and opened the door.
66. Over the radio, there had been some misunderstanding of the officer’s
location and initially staff made their way to A wing. Another officer
was working in the control room (COMMS) and responded to the first
officer on scene’s call over the radio. He explained in interview that the
first officer on scene was carrying a radio, identified as Alpha Two.
When an officer triggers the transmit button, they are trained to wait a
second before talking. In his haste, it would seem that the first officer
on scene began to talk immediately, thus the message that staff heard
in COMMS was “medical assistance, alpha two” and as a consequence
directed staff to A wing rather than C wing. The first officer on scene
then radioed again to correct the location relayed to staff. The layout of
the wings is such that officers were able to get to C wing very quickly.
67. The first officer on scene laid the man out on the floor and cut the
ligature from around his neck using the anti-ligature knife that is carried
by all officers. He could not see any movement in the man’s chest to
indicate breathing. After putting on his mask, he started to give
breaths. By this time other staff arrived. Another officer began chest
compressions.
68. A nurse was coming back from lunch and heard the emergency call on
the radio of a colleague with whom she was walking. As with the other
staff, she initially attended A wing before setting off for C wing. In
interview, she said that when she arrived at the cell one officer was
doing mouth to mouth and the other was performing chest
compressions. The nurse checked with staff that an ambulance had
been called and then took over the compressions. The man was
clammy to touch and from his colour she believed him to be dead.
69. Hotel 2 is the emergency medical response radio and it is the
responsibility of the nurse carrying it to respond to any emergency call.
At Bedford it seems that the radio is sometimes switched off for an
hour at lunchtime and any emergency calls are put through to the
healthcare centre. On this occasion, the radio was turned off but the
Hotel 2 nurse was in the prison and heard the call coming through a
colleague’s radio. The message came over as “medical assistance to
A wing”. The Hotel 2 nurse did not take any medical equipment with
her. She arrived at the cell at the same time as the nurse coming back
from lunch. She then went to get the emergency bag from the main
wing office, returned to the cell and then left again to collect the
defibrillator from healthcare. Once back at the cell, the Hotel 2 nurse
was unable to attach the plugs into the machine. In interview with my
investigators, she said she felt this was because she was panicking.
The nurse coming back from lunch said that she did not try the lead
herself but did have a quick look with the Hotel 2 nurse.
70. Nurses and discipline staff continued cardio pulmonary resuscitation
until the paramedics arrived at 1.50pm and took over. Sadly, the man
was pronounced dead at 2.05pm by the prison GP.
71. The cellmate had been taken to the Listeners’ suite by another officer.
(Listeners are prisoners trained by the Samaritans to provide
confidential support to other prisoners.) The officer took a statement
from the cellmate who was later interviewed by the police. He felt that
the prison dealt with him well. All staff involved were offered the
services of the care and welfare team and all prisoners on ACCT
documents were checked in line with guidelines.
Contacting the man’s family
72. Given that the man had not given any next of kin details, staff at
Bedford initially contacted Wormwood Scrubs. He had given his
grandmother’s phone number as a number on the PIN phone system
(in which each prisoner is given a unique number to access the
telephone system). Unsure of her age and state of health, staff did not
want to contact her without other information. The man had spoken to
his cellmate about previously staying with a vicar in the London area. It
would seem that the prison chaplain then worked her way through the
telephone book until she traced the vicar who was able to tell her a little
bit more about his grandmother.
73. The prison’s family liaison officer and the chaplain then went to see the
man’s grandmother the next morning and telephoned his parents from
his grandmother’s house. The family are not convinced that this delay
was necessary. Their view is that, despite being elderly, the man’s
grandmother should have been informed on the day regardless of any
other factors. Whilst respecting the family’s opinion, I am not minded
to criticise staff for this decision. The prison staff made their judgement
without the benefit of knowing his grandmother and, in my view, the
care that they took was appropriate.
74. When my colleagues met the man’s family they were very
complimentary about the leaflet given to them by the prison when they
were notified of his death. However, in general, his family feel that the
quality of the liaison with them was very poor. They spoke negatively
about obstacles raised by the prison service regarding practical
arrangements for the man’s grandmother to visit with the rest of the
family due to her restricted mobility. Subsequently, perfectly
acceptable arrangements were made for the family to meet the
Governor on the ground floor but they felt there had previously been a
degree of insensitivity. They also commented that they had been told
by the police that the cellmate had said he would talk to them but
thought that they were put off doing this by prison staff.
ISSUES
Operation Safeguard
75. When the man left Wormwood Scrubs to attend court on 12 April 2007,
he expected to return there later that day. However, given the high
prison population some prisons became full and were “locking out”
under Operation Safeguard, and this meant prisoners were being
accommodated overnight in police cells. Depending on which police
stations had cells available, prisoners were being taken outside the
area of the escort contractors. This made it impossible for them to be
returned to the originating establishment the next day if a space
became available as a different contractor was involved. Another
factor was that there was a disinclination to return prisoners to areas of
high demand once they had been transferred out of area.
76. Unexpected transfers and moves at short notice are far from ideal and
recognised as unsettling for prisoners. Under normal circumstances,
staff try to avoid them. However, pressures on the prison population
have made this unavoidable. Operation Safeguard allows for
exceptions for certain categories of prisoners.
77. Section 5.3 of the Prison Service Instruction governing Operation
Safeguard (PSI 30/2006) states:
“Every effort must be made 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’.
(cid:127) Juvenile prisoners;
(cid:127) Female prisoners;
(cid:127) Those at risk of self-harm on open ACCT or F2052SH;
(cid:127) Those with significant health care issues, including:
(cid:1) Prisoners undergoing assessment for, or due transfer, under
the MHA 1983
(cid:1) Any prisoner identified by the prison health team as
unsuitable on clinical grounds (This must be clearly identified
on the PER)
(cid:1) Any other prisoner with a significant physical or mental
health problem that the health care provider to the Police
station feels is clinically unsuitable for their locally available
service eg clinically unstable substance misuse problem or a
patient undergoing complicated treatment;
(cid:127) Vulnerable prisoners
(cid:127) Prisoners with a Crown Court trial in progress (including those
from the Court of Appeal (Criminal Division) – COACD;
(cid:127) All category A prisoners including potential category A prisoners;
(cid:127) Escape list prisoners or prisoners with a documented history of
disruptive behaviour;
(cid:127) Prisoners with mobility problems;
(cid:127) Prisoners with language difficulties.”
78. With the exception of those “identified by the prison health team as
unsuitable on clinical grounds”, prisoners falling into any of the other
categories are easily identifiable. It is not clear, however, whether a
prisoner being stabilised on a methadone maintenance programme in
one establishment would fall into this category. In these
circumstances, it is the transfer to another establishment with limited
detoxification programmes that would render them “unsuitable”.
The Prison Service should undertake a review of the criteria of
those deemed suitable for Operation Safeguard giving specific
consideration to prisoners on drug maintenance programmes.
Clear guidance should be given to all prison staff following the
review.
79. For the man to have been returned to Wormwood Scrubs, staff would
have had to have marked his PER with “return to discharging
establishment”. Although staff at Wormwood Scrubs expected him
back and told my investigators that they had held his cell, they did not
recognise that they needed to identify him as being required to come
back. They believed that this decision was a matter for the Population
Management Section (PMS).
80. The man was one of three prisoners from Conibeere Unit who went to
court on 12 April. The other two were returned and their PERs were
examined by my investigators. They also did not have “return to
discharging establishment” written on them. One went to Crown Court
so may have been returned for that reason. It is also possible that they
returned simply because it was earlier in the day and before
Wormwood Scrubs reached its operational capacity.
The Governor of Wormwood Scrubs should ensure his staff are
aware that the provisions of Operation Safeguard permit them to
make representations concerning prisoners who should return to
their establishment.
The man’s ulcer
81. When the prison GP saw the man at his reception interview, he was
aware of his history of a bleeding stomach ulcer both from his account
and his records. The prison GP prescribed diclofenac. The clinical
review suggests this was not appropriate. The clinical reviewer
comments that diclofenac is a drug that is contra-indicated in patients
with previous or active peptic ulceration. The prison GP, in interview,
said that he was conscious of this incompatibility but prescribed
diclofenac regardless. Following their second consultation, when the
man reported the presence of blood when vomiting, the prison GP
changed the medication. Additionally, the prison GP did not continue
with the omeprazole medication that the man had been prescribed at
Wormwood Scrubs until after his second consultation with him.
82. I am not a clinician and it would not be right for me to criticise the
prison GP given the pressured circumstances under which he found
himself that evening, and the obviously difficult consultation with the
man. However, it is of concern that little consideration appears to have
been given to his pre-existing medication, or his presenting clinical
conditions.
The healthcare manager at HMP Bedford should ensure that the
care of substance users is planned taking account of the individual
needs of the patient as well as clinical needs which may
contraindicate the prescribing and issue of certain medications.
Substance misuse treatment
83. The only option offered to opiate drug users at Bedford is lofexidine
along with other medication to ease the withdrawal symptoms. The
clinical reviewer has expressed concern about the low dose of
lofexidine used at Bedford: “the use of low dose lofexidine to manage
symptoms of opiate withdrawal does not conform to national guidelines
and needs to be modernised in line with current thinking”.
84. As noted earlier in this report, the Chief Inspector of Prisons has
highlighted the need for the clinical management of substance users at
Bedford to be urgently reviewed. At the time of the man’s death a year
later, the options available for opiate users remained limited. The
clinical reviewer makes the following recommendation in his clinical
review which I strongly endorse:
The Governor and Chief Executive of the PCT should give urgent
consideration to the overall planning of a sound and comparative
substance misuse service for prisoners.
The cell move
85. The man moved into cell C3-10 on the afternoon of 16 April. My
investigators were unable to identify the member of staff who
sanctioned this move as none of the correct documentation had been
completed. This included the cell location review which asks a number
of questions regarding the reason for the move and the risk
assessments of both the prisoner moving cells and the occupant of the
cell to which he is moving. To answer these questions the cell sharing
risk assessment forms of both prisoners would have had to have been
checked. The move should then have been added to a list of ‘cell
changes’ and the roll board in the office updated.
86. In this case, there was nothing of significance on either the man’s or
his cellmates cell sharing risk assessment. This is very disappointing
as the use of cell sharing risk assessments is an essential part of the
safer custody agenda. Other cell moves that day were documented
and the man’s move was recorded on the local computer system.
The Governor of Bedford must remind all staff of the importance of
completing all the relevant documentation with regard to cell
moves.
The response by medical staff on 17 April
87. The clinical reviewer has written extensively about the response of
healthcare staff on 17 April. I repeat his comments here and endorse
all his conclusions and recommendations.
On-call radio, Hotel 2
88. It is accepted practice within the prison that the Hotel 2 radio is
switched off at lunchtime for one hour every day and any emergency or
other calls are directed by telephone to healthcare from COMMS.
89. On the day, Hotel 2 did have the radio switched off but heard the call
on another person's radio and attended despite being on lunch break.
Neither nurse who responded actually heard the call on a radio which
they had on their possession. There is no note of any other person
from healthcare responding other than the prison GP when he was
called on his radio some time afterwards.
90. The current system of switching off the on-call nurses' radio (Hotel 2)
for one hour at lunchtime is a practice that is less than safe. Relying
on the use of telephone calls to pass on emergency calls to healthcare
during this time is hazardous for obvious reasons.
The PCT must remind staff that the on-call radio should not be
switched off at lunchtime but passed between members of
healthcare to ensure appropriate cover for emergencies is
seamless and guaranteed.
The scene of the incident and resuscitation
91. The initial delay in reaching the man’s cell due to the incorrect
identification of the location as A wing, rather than C wing as it should
have been, resulted in a loss of between two to three minutes.
92. No resuscitation or other equipment was immediately taken to the
scene by any of those responding. The healthcare manager said she
would expect such equipment to be taken at all times an emergency
call is attended by a nurse. One of the nurses who did attend had to
leave the cell on two occasions to get resuscitation equipment, once to
the wing to fetch the resuscitation bag and then to healthcare to get the
defibrillator. The Hotel 2 nurse was then unable to attach the
defibrillator to the leads which would enable the defibrillator itself to be
connected to the chest pads. She described "panicking" as the reason
for this failure. No defibrillator was therefore available when it was
needed.
93. I also note that no ambubag was used during resuscitation. One of the
nurses says in her statement that mouth to mouth is as effective as an
ambubag. However, ambubags, when available and used proficiently,
are widely regarded as the safest and best way of both securing
effective respiration and allowing oxygen to be attached and
administered. There is no note of any airway being used during the
resuscitation process nor any oxygen being used.
94. The first nurse to attend to the man ensured the ambulance had been
called. The prison GP was called by a radio message some time
afterwards and arrived at the cell at the same time as the ambulance
crew. This was apparently 15 minutes (or more) later.
The Chief Executive of the PCT should urgently consider the
training needs of all staff who may find themselves dealing with
emergencies and plan for any necessary training to be given. Staff
need to be familiar with the location of all emergency equipment
and proficient in its use. They should also be both familiar and
proficient in all other aspects of the processes necessary in dealing
with emergency medical situations (eg CPR, mouth to mouth,
ambubag use).
Emergency Coding System
95. It has been established that there was no existing coding system within
the Bedford prison for highlighting the potential nature, severity and
actions needed for emergency incidents.
96. In her statement, the healthcare manager felt that the introduction of an
emergency coding system was unnecessary due to the imminent
introduction of permanently carried emergency rucksacks by Hotel 2.
However, this system has yet to be introduced and it is my
understanding that there is still no emergency coding system in place.
I recommend that the Chief Executive of the PCT urgently
considers introducing a coded radio call system to ensure that
healthcare staff attending an emergency are able to take the
necessary equipment to the incident and thereby manage it
effectively.
Emergency Bags
97. The clinical reviewer could not establish exactly how many emergency
bags are currently in the prison, where these may be located and what
they actually contain.
98. Emergency bags should be readily and easily available throughout the
prison so that they can be speedily accessed whenever they are
needed. Their contents should be consistent and checked on a daily
basis. The formal arrangements surrounding both the placement,
contents and use of emergency bags and regular/refreshing of
resuscitation training for all staff should be reviewed to ensure proper
governance is in place and evidence-based best practice is followed.
The Governor should consider the immediate introduction and use
of strategically placed emergency bags that can easily be moved to
the scene of an incident and contain the necessary equipment to
manage incidents effectively until the arrival of medical or other
paramedic support. Urgent consideration should also be given to
placing suitable portable Automated External Defibrillators
strategically within the prison with easy access in the event of an
emergency.
Conclusion
99. Prisoners detoxifying from drugs are especially at risk of suicide or self-
harm. The man was on a maintenance prescription of methadone
before being relocated under Operation Safeguard and ending up in a
prison where methadone is not in use. The evidence of his cellmate is
that he suffered pains of opiate withdrawal, and four days after arriving
at the new prison he took his own life.
100. The man left no note to explain his actions and there can be no
certainty as to what was in his mind when he tied the ligature around
his neck. However, it is difficult to conclude other than that his transfer
and change in medication were relevant factors in his death.
RECOMMENDATIONS
The Governor of Wormwood Scrubs should ensure his staff are aware
that the provisions of Operation Safeguard permit them to make
representations concerning prisoners who should return to their
establishment.
The Prison Service accepted this recommendation, and said:
“The Governor has reminded staff but due to population pressures compliance
is not always possible.”
The healthcare manager at HMP Bedford should ensure that the care of
substance users is planned taking account of the individual needs of the
patient as well as clinical needs which may contraindicate the
prescribing and issue of certain medications.
The Prison Service accepted this recommendation, and said:
“All prisoners who use the substance misuse service undergo a full
assessment. Prisoners are given a health screen by a substance misuse nurse
and then are either maintained or detoxified as required, including Methadone
maintenance.”
The Prison Service updated their action plan response six months after the
recommendations were made and said:
“Completed. A new protocol is awaiting ratification by the PCT and partnership
board.”
The Governor and Chief Executive of the PCT should give urgent
consideration to the overall planning of a sound and comparative
substance misuse service for prisoners.
The Prison Service accepted this recommendation, as above. The Prison
Service updated their action plan response six months after the
recommendations were made and said:
“Completed, we are currently in the process of becoming a third wave IDTS
site, due for commencement April 2009”
The Governor of Bedford must remind all staff of the importance of
completing all the relevant documentation with regard to cell moves.
The Prison Service accepted this recommendation, and said:
“The Governor will remind all staff of the importance of completing all relevant
documentation with regards to cell moves.”
The Prison Service updated their action plan response six months after the
recommendations were made and said:
“Completed, Governors Order issued April 2008.”
The PCT must remind staff that the on-call radio should not be switched
off at lunchtime but passed between members of healthcare to ensure
appropriate cover for emergencies is seamless and guaranteed.
The Prison Service accepted this recommendation, and said:
“A system has been implemented ensuring that the on-call radio is not
switched off and is covered by a qualified nurse 24 hours a day.”
The Prison Service updated their action plan response six months after the
recommendations were made and said the action from this recommendation
had been completed.
The Chief Executive of the PCT should urgently consider the training
needs of all staff who may find themselves dealing with emergencies and
plan for any necessary training to be given. Staff need to be familiar with
the location of all emergency equipment and proficient in its use. They
should also be both familiar and proficient in all other aspects of the
processes necessary in dealing with emergency medical situations (eg
CPR, mouth to mouth, ambubag use).
The Prison Service accepted this recommendation, and said:
“A training review has been completed for all clinical staff, this has resulted in
all staff now being compliant with the PCT’s training matrix. Clinical staff are
also subject to twice yearly updates in CPR and Anaphylaxis.”
The Prison Service updated their action plan response six months after the
recommendations were made and said the action from this recommendation
had been completed.
I recommend that the Chief Executive of the PCT urgently considers
introducing a coded radio call system to ensure that healthcare staff
attending an emergency are able to take the necessary equipment to the
incident and thereby manage it effectively.
The Prison Service accepted this recommendation, and said:
“The emergency clinical response procedure was reviewed, with consideration
given to introducing a coded radio system. As a result of that review, all
emergency calls are treated as urgent and an emergency bag is taken to every
call.”
The Prison Service updated their action plan response six months after the
recommendations were made and said:
“Completed. A draft document is now with the integrated governance group of
the PCT for comments and to ascertain risk.”
The Governor should consider the immediate introduction and use of
strategically placed emergency bags that can easily be moved to the
scene of an incident and contain the necessary equipment to manage
incidents effectively until the arrival of medical or other paramedic
support. Urgent consideration should also be given to placing suitable
portable Automated External Defibrillators strategically within the prison
with easy access in the event of an emergency.
The Prison Service accepted this recommendation, and said:
“Four Automated External Defibrillators (AED’s) and two fully equipped
resuscitation bags have been strategically positioned around the
establishment, with a further two resuscitation bags planned in the very near
future. The emergency response nurse also carries a fully equipped
resuscitation bag to all incidents.”
The Prison Service updated their action plan response six months after the
recommendations were made and said:
“Completed. There is 5 AED’s situated around the prison and an emergency
bag on all wings. Two nurses respond to emergencies during the day and one
at night.”
Additional recommendation
The Prison Service should undertake a review of the criteria of those
deemed suitable for Operation Safeguard giving specific consideration to
prisoners on drug maintenance programmes. Clear guidance should be
given to all prison staff following the review.
The Prison Service accepted this recommendation, and said:
“NOMs agency will review the criteria within a wider already planned review of
Operation Safeguard.”