Individual at Glen Parva

Investigation into the circumstances surrounding the
death of a man
at HMPYOI Glen Parva in June 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
Final Report:
Date: September 2010
This report considers the circumstances surrounding the death of a man in HMYOI
Glen Parva on 2 June 2009. The man was found hanging in his cell at
approximately 4.30am. He was 20 years old.
I offer my sincere condolences to the man’s mother, brother, sister-in-law, and all
those who knew him. I regret the delay issuing my report and any additional distress
this may have caused the man’s family.
The investigation on which this report is based was conducted by an investigator on
my behalf. I would like to thank the Governor and Deputy Governor, as well as a
Governor, who acted as the liaison for my office. I am also grateful to the members
of staff at Glen Parva who co-operated fully with the investigation. In addition, I
thank the doctor, who conducted a review of the man’s clinical care. He was
appointed by Leicestershire Partnership Trust.
The man first entered the prison system in April 2008. He served the majority of his
sentence at HMP Portland and was released on licence in January 2009. My report
covers the man’s time at Portland in some detail and, although I make no
recommendations to the Governor, I draw the report to his attention. Unfortunately,
he was returned to custody only two weeks after his release. In March, the man was
transferred from Portland to HMP Feltham, and then to Glen Parva. At the time of
his death, he had been in the prison for just over two months.
Throughout his time in custody, the man struggled with low mood, depression, and a
propensity to self-harm. He was subject to additional monitoring because of
concerns around self-harm and suicide on several occasions. At the time of his
death, though, he was not considered to be at imminent risk.
I have made a recommendation about the quality of written entries for people
considered to be at increased risk of suicide. My other main recommendations also
concern the monitoring and recording process for those at risk.
This is the fifth apparently self-inflicted death in Glen Parva since I took responsibility
for investigating all deaths in prison custody in 2004. My most recent investigation,
following a death in July 2007, also highlighted issues around the quality of written
records for suicide and self-harm monitoring.
Jane Webb
Acting Prisons and Probation Ombudsman June 2010
Final Report: 2
Date: September 2010
CONTENTS
Summary
The Investigation Process
HMYOI Glen Parva, HMYOI Portland & HMYOI Feltham
Key Findings
Issues
Assessment, Care in Custody and Teamwork (ACCT)
Single cell accommodation
Prison transfers
Clinical care
Events of 2 June 2009
Allegations made after the man’s death
Issues raised by the man’s family
Conclusions
Recommendations
Final Report: 3
Date: September 2010
SUMMARY
The man was sentenced to 18 months’ imprisonment on 17 July 2008. It was his
first conviction and prison sentence. He transferred from HMP Feltham to HMP
Portland on 24 July. At Portland, an Assessment, Care in Custody and Teamwork
(ACCT) document (the ACCT process is used by the National Offender Management
Service to monitor and support prisoners at risk of self-harm or suicide) was
immediately opened because of concerns about self-harm. On the following day, 25
July, Levi harmed himself using a piece of plastic which he broke off his bed, and
was moved to a cell with a closed circuit television (CCTV) camera.
The man was assessed by a mental health nurse on 28 July as posing a high risk of
self-harm and suicide. He remained in the camera cell. Over the next few days, the
man was seen again on several occasions by the nurse and by his offender
supervisor. His mood remained low and there were continued concerns about self-
harm.
On 8 August, the man moved from the camera cell to a gated cell (a cell with a gated
rather than a solid door, to facilitate easier observation), on a different unit, but he
harmed himself again using a radio aerial and was subsequently returned to the
camera cell. The next day, 9 August, he was again moved to a gated cell and two
days later to a skills development unit. Reviews of Levi’s ACCT document indicate
that his mood improved over the following month. He integrated well into the unit
and engaged in activities such as the unit talent show. On 16 September, the man’s
ACCT document was closed as the members of staff involved felt that his level of
risk had reduced. A post-closure review (a meeting to look at a prisoner’s progress
after the closure of the ACCT) was held on 23 September. Staff at the review
reported that Levi felt settled and had not thought of harming himself recently.
Eight days later, on 1 October, the man was seen by the mental health nurse and
appeared unhappy. On 4 October, a second ACCT document was opened after he
told an officer that he felt like harming himself. He said he felt very miserable and
did not care if he lived or died. The man was moved to an anti-ligature cell on a
different unit, and returned to the skills development unit the following day. He
reported feeling happier. However, over the next few days and weeks, the man’s
mood seemed to fluctuate a great deal. Some reports indicate that he was in high
spirits, whilst others state that he was very low in mood. On 10 October, the man
was found sitting on the floor of his cell, clutching his knees to his chest. A week
later, on 17 and 19 October, he was reported to be joking with unit staff and chatting
about guitar instruction, but on 23 October he rang his cell alarm to say he felt like
‘doing something’.
Despite these variations in mood, the man seemed to improve and, on 12 November
his ACCT document was closed. Three days later, however, he seriously burned his
arm using a cigarette lighter, and had to be restrained to prevent him from harming
himself further. He was moved to a different unit and placed under constant
observation. Another ACCT document was opened and, on 16 November, the man
told the assessing officer that his depression was like a switch and overtook him
without warning.
Final Report: 4
Date: September 2010
Again, the man seemed to improve, and his ACCT document was closed on
3 December. During the post-closure review eight days later, the man said he would
approach members of staff if he felt low in mood. On the same day, in an interview
with a mental health nurse, the man said he felt positive about his future.
The man was released from Portland on 6 January 2009, with licence conditions
including residence at a probation approved premises. On 21 January, 15 days after
his release, he was returned to custody after breaching his licence conditions. He
spent a week at HMP Dorchester before being transferred back to Portland. On 16
February, the Parole Board recommended that the man should remain in custody
until his sentence end date of 7 October.
The man was assaulted by three other prisoners on 21 February and his injuries
were treated at an outside hospital. He returned to the prison and was located on a
standard residential unit. Two days later, he harmed himself by burning his arm over
the previous burns. An ACCT document was opened. The man said he had “never
felt worse” and wanted to die. His mood fluctuated and staff on the unit expressed
concerns about whether they could effectively care for someone with such complex
needs. Over the next three weeks, the man was twice moved temporarily to another
unit for increased observation.
On 19 March, the possibility of transferring to Feltham was suggested to the man,
who was initially reluctant. However, members of staff spoke to him about the
benefits of a dedicated healthcare unit and the ways in which his needs could be
managed more effectively. He became more positive about moving and, on 24
March, was transferred to Feltham. However, after assessment he did not meet the
criteria for the healthcare unit and was transferred to Glen Parva on 31 March.
The ACCT document opened on 23 February remained open and subject to regular
reviews throughout this period. A review was held on 1 April in the prison’s induction
unit. The man was described as a mature and talkative young man. He was seen
by a mental health nurse the following day who reported that he had settled well but
continued to struggle with his mood.
On 7 April, one week after arriving at Glen Parva, the man moved to a normal
residential unit. He had shared a cell with a prisoner on the induction unit, and
continued to share with the same man after the move. Members of staff recalled that
the man was very quiet and withdrawn when he arrived, but improved over the
following week. An entry in his ACCT document on 11 April noted that he was
laughing and joking with a large group of his peers whilst out of his cell during the
association period.
The man appeared to settle over the subsequent fortnight. No concerns were raised
about self-harm. On 28 April, he met a mental health nurse and was accepted on to
the mental health in-reach team’s (MHIT) caseload. This meant he would be seen
regularly for support and advice. On the same day, a decision was made, in
conjunction with the mental health nurse, to close his ACCT document. The post-
closure review meeting was held on 5 May, and no concerns were raised.
Final Report: 5
Date: September 2010
Two days later, the mental health nurse wrote in the man’s clinical record that he
was again very unhappy. On 15 May, she wrote that, although he was feeling more
relaxed, he continued to isolate himself in his cell and did not leave for association
activities. Three days later, on 18 May, the nurse wrote that she had discussed with
him the benefit of interacting with others, but he remained unwilling to consider the
option.
The man saw a mental health nurse on 27 May and asked for a single cell, saying he
would benefit from his own space and some time to himself. The unit’s senior officer
discussed this with the mental health nurse, and they decided to give the man a
single cell. He moved on the same day.
At approximately 4.30am on 2 June, the patrolling officer support grade (OSG) saw
what he thought was the man standing in front of the window in his cell. After being
unable to get a verbal response, the OSG turned on the cell light and saw that the
man was hanging from a ligature that had been fashioned from a bed sheet and
attached to the window bars. The OSG requested immediate assistance. Other
officers and a nurse attended within minutes. Resuscitation was attempted but was
unsuccessful. The man was pronounced dead by paramedics on the scene at
5.11am.
I pay particular attention to issues relating to the ACCT process, single cell
accommodation, and transfers within the prison system. I also look into a number of
allegations that were made after the man’s death, as well as issues raised by his
family. I make eight recommendations and endorse a further two made by the
clinical reviewer.
Final Report: 6
Date: September 2010
THE INVESTIGATION PROCESS
1. The investigator opened the investigation on 2 June 2009 and arranged to
visit the prison three days later. During this visit, the investigator met with the
PPO’s liaison officer and Glen Parva’s Head of Residential Care, Governor.
The Governor provided the documentation relating to the man’s time in
custody. The investigator also met the family liaison officer appointed by Glen
Parva, as well the Independent Monitoring Board (IMB). Finally, the
investigator met the governor at the time and the deputy governor.
2. The IMB expressed concern that the man was in four prisons (Portland,
Dorchester, Feltham and Glen Parva) within a relatively brief period of time.
He felt that this would be unsettling for any prisoner, but was likely to be
particularly traumatic for the man given his mental health problems. He was
also concerned that after being subject to self-harm and suicide monitoring for
a relatively long period before his transfer, it was ended shortly after his
arrival. Furthermore, the IMB told my investigator that on the morning of the
man’s death the IMB was not contacted until 7.45am, some three hours after
he was found hanging in his cell.
3. One of my family liaison officers (FLOs), contacted the man’s brother who
was his nominated next of kin. During telephone conversation, the brother
raised a number of concerns. He said the man suffered from bipolar disorder,
a condition characterised by extreme highs and lows of mood, and wondered
if the man had been considered at increased risk of self-harm and suicide as
a result. The man’s brother asked about additional monitoring for prisoners at
risk. He also asked why the man was in a single cell, given his mental health
issues. Finally, he asked what the man had used to fashion a ligature.
4. The FLO also contacted the man’s mother. She welcomed a visit to discuss
her concerns surrounding the man’s time in custody and the circumstances of
his death. The investigator and FLO met with the man’s mother on 28 July at
a central London hotel. Although she had instructed solicitors, their
representative was not present at the meeting.
5. The man’s mother raised a number of issues during the meeting and asked
that her questions be answered as part of the investigation. She mentioned
that she had discovered since his death that he had suffered from bipolar
disorder. She questioned how this was managed in prison and what
medication he had taken. She also asked why the man was not in the
healthcare unit, given his illness. On a similar note, his mother said she was
aware that he had been in a single cell and questioned this decision based on
his vulnerability and bipolar disorder.
6. Regarding the man’s time in custody, his mother said she had been told by
the man’s brother that there had been two attempts on the man’s life whilst he
was in prison custody. She said that a prisoner was stabbed because he had
been mistaken for the man, and that on another occasion there had been an
incident during a game of pool. She felt that these attacks might have been
racially motivated as the man was of mixed race and had been bullied as a
Final Report: 7
Date: September 2010
result of this is the past. She asked if it was possible to confirm whether these
attacks took place, and if so, what steps were taken to protect the man.
7. In terms of the night of the man’s death, his mother had a number of
concerns. She said it was her understanding that he had been subject to
checks by staff every two hours, and questioned why they were no more
frequent given his bipolar disorder. She felt strongly that the man should have
been subject to special monitoring in view of his ongoing depression. The
man’s mother was also concerned that members of prison staff had not made
lengthy attempts to resuscitate him. She understood that their attempts had
ceased before the paramedics arrived. She asked whether this was the case,
and if so, why this happened before outside medical personnel arrived at the
prison.
8. The man’s mother said her experience of family liaison from Glen Parva had
not been good. She felt that whilst the prison family liaison officer had initially
been caring and pleasant towards her, his attitude had changed and he had
inappropriately taken sides with the man’s brother. She also mentioned a
distressing voicemail message left on her mobile telephone by the prison
family liaison officer which appeared to be intended for someone else. She
said the nature of the message, referring to a prisoner who was alive and well
at the prison, was particularly distressing in light of her recent loss.
9. The solicitor acting for the man’s mother received a copy of the draft report
and made written representations in response. Where appropriate,
amendments were made and have been incorporated into this final version of
the report. Other issues were addressed by letter, outside the report.
10. The investigator returned to Glen Parva to interview prisoners and members
of staff in October 2009. Interviews took place in October and November,
with 15 members of staff and four prisoners seen. In December, the
investigator interviewed the man’s offender manager at her central London
office.
11. Leicestershire Partnership Trust appointed a doctor to conduct a review of the
man’s clinical care whilst in custody. The purpose of a clinical review is to
examine the medical care that a prisoner received whilst in custody, which
should be of an equivalent standard to what might have been expected in the
community. The clinical reviewer consulted the man’s medical record and
also interviewed a member of the clinical team at Glen Parva in conjunction
with my investigator. His findings are summarised in this report and the full
clinical review is included as an annex.
Final Report: 8
Date: September 2010
HMYOI Glen Parva
General
12. Glen Parva is a young offender institution located near Leicester. It has a
maximum operational capacity of 808, and holds remanded, unsentenced and
convicted prisoners aged between 18 and 21 years. Since it opened in 1974,
the establishment has always held young offenders.
13. Prisoners spend their first six nights in a dedicated induction unit, before
moving to one of the nine other residential units. In addition, there is a
separate segregation unit and a healthcare centre. At the time of my
investigation, the healthcare centre was closed to in-patients due to major and
protracted building work.
14. Healthcare at Glen Parva is provided by Leicestershire and Rutland Primary
Care Trust (PCT). A primary mental health team is managed by the prison’s
healthcare department, and Leicestershire Partnership Mental Health Trust
provides a mental health in-reach team under the management of
Northamptonshire NHS Foundation Trust.
Performance
15. The Ministry of Justice produces quarterly performance figures for all prisons
in England and Wales. Every establishment is given a rating between 1 and 4
based on 34 agreed performance indicators. For the first quarter of 2009-
2010 (April, May and June 2009), Glen Parva received a rating of 3, indicating
good performance (the maximum score of 4 indicates exceptional
performance). During quarters 2, 3 and 4 (the most recently available figures
at the time of writing), the prison maintained its rating of 3.
16. HM Chief Inspector of Prisons inspected Glen Parva in November 2009,
though her report had not yet been published at the time of writing. The most
recent published report about Glen Parva concerned an unannounced
inspection in 2007, following the previous full inspection in 2004. The prison
had shown marked improvement, and of the 57 recommendations made in
2004, 37 had been fully implemented and ten implemented in part. The report
found that Glen Parva was now “performing reasonably well across all the
main areas that constitute a healthy prison”. The establishment was
described as essentially safe, although the Chief Inspector thought that more
needed to be done to address bullying, and that the suicide prevention
arrangements needed to focus on quality rather than simply process. Both of
these issues are pertinent to this case and are discussed in the body of the
report.
17. The most recent report issued by the Independent Monitoring Board (IMB) at
Glen Parva relates to the two year period from December 2006 to November
2008. IMBs are made up of independent, unpaid members of the public, and
monitor the standards of prisons. The Board stated that Glen Parva had
continued to improve, though it also expressed concerns about the living
Final Report: 9
Date: September 2010
standards, saying that “Units 1, 2 and 5 are inadequate and well below the
normal standard of accommodation; the heating in these units is unreliable,
with some heaters not working at all, windows need replacing, and the
showers are unpredictable”.
Previous deaths at the prison
18. My office has been responsible for investigating deaths in custody since April
2004. Prior to the man’s death, I investigated four other apparently self-
inflicted deaths. Two of the deaths occurred in 2005, one in 2006 and the last
in July 2007. Although three of the four deaths were by hanging, they
involved few similar circumstances to the man’s death. The most recent
death, in 2007, followed a cell fire. The investigator in that case highlighted
deficiencies in the quality of documents relating to suicide and self-monitoring.
I address covered the same issue in this report.
HMYOI PORTLAND
19. Portland is on England's south coast and holds young men aged 18 to 21. It
has a maximum operational capacity of 624. It has a number of units serving
different purposes. Of those mentioned in this report, Drake and Nelson are
normal residential units, Grenville is the induction unit, Beaufort is a skills
development unit, and Collingwood usually houses those who have earned
extra privileges.
HMYOI FELTHAM
20. Feltham is located in the Greater London area, and has a maximum
operational capacity of 762. In addition to young adults aged 18 to 21,
Feltham also holds young men aged 15 to 18, though the different age groups
are housed separately. The units mentioned in this report are Kingfisher and
Lapwing, which are the induction and medical inpatients unit respectively.
ASSESSMENT, CARE IN CUSTODY AND TEAMWORK (ACCT)
21. The National Offender Management Service uses the ACCT process as a
way of monitoring and providing support to prisoners identified as being at risk
of self-harm or suicide. This is used in all prisons and young offender
institutions across England and Wales. All members of staff should receive
basic ACCT training and be able to open a document, as well as making
appropriate entries in the ongoing record. Case reviews should comprise no
fewer than two members of staff and also involve the prisoner subject to the
ACCT document. These reviews should also, ideally, be multi-disciplinary.
When staff members conducting a review determine that risk has been
significantly reduced or is no longer evident, and it is felt that further intensive
support and monitoring is not required, the document can be closed. A post-
closure review should take place seven days later to confirm that risk remains
reduced. Ideally, this review should also be multi-disciplinary.
Final Report: 10
Date: September 2010
KEY FINDINGS
22. The man was initially remanded to HMP High Down on 7 April 2008, and
remained there until his conviction on 12 June, whereupon he was transferred
to HMP Feltham. On 17 July, he was sentenced at Southwark Crown Court to
18 months’ imprisonment and, on 24 July, transferred to HMP Portland.
Transfer to HMP Portland
23. When prisoners arrive at a prison, they undergo a number of basic
assessments in the reception area. One of these is a cell sharing risk
assessment (CSRA), the purpose of which is to identify any risks or concerns
associated with the prisoner sharing a cell. The CRSA completed for the man
at Portland mentioned that he had harmed himself one week previously, and
that an Assessment, Care in Custody and Teamwork (ACCT) document
would be opened.
24. Following the decision to instigate the ACCT process, a number of documents
are completed. The first is known as a Concern and Keep Safe form. In the
man’s case, it was completed by an officer, who indicated that he had a very
low mood and had self-harmed one week earlier by burning his arm with a
cigarette. An Immediate Action Plan was then completed. It stated that the
man would have access to a telephone linked to the Samaritans, and be
observed by wing staff three times during the day and twice during the
evening. It did not specify whether there would be any additional checks
overnight. (The front cover of the document, however, specifies three
conversations and observations during the hours of 8.00am and 8.30pm, and
two observations overnight. The ACCT ongoing record also shows that the
man was checked overnight.) The form also stated that, whilst there were no
concerns about cell sharing, the man was at that time located in a single cell
and was happy with the arrangement.
25. The following day, 25 July, an ACCT assessment interview was conducted by
an officer. Such interviews are conducted by trained ACCT assessors and
are intended to gain a more detailed overview of a prisoner subject to the
ACCT process. The record of the interview states that the man suffered from
bouts of depression and that they were not specifically related to his
imprisonment. He said that he felt suicidal after being accused of misconduct
at work (an event which precipitated the offence for which he was
imprisoned), and burned his arm and face with a cigarette as a result of
feeling that his situation was hopeless. The man also spoke about a suicide
attempt two months earlier, which involved him taking ten strong migraine
tablets after finding himself consistently unhappy. During the interview, the
man said he did not feel suicidal at that time, but suffered disturbed sleep and
worrying thoughts. Despite this, an Action Following Assessment form
completed only three hours later suggested that the man now felt suicidal and
had experienced a dramatic increase in depressive symptoms since the
earlier interview. He spoke about hearing the voice of his mother saying she
wanted him dead, and also said he wanted to end his life using a razor blade.
Final Report: 11
Date: September 2010
26. As a result of the concerns raised, he was placed in an anti-ligature cell (a cell
designed to substantially reduce the number of available ligature points) and
an urgent referral was made for mental health assessment.
27. Two hours later, a self-harm/attempted suicide form was completed by a
Senior Officer. This stated that, whilst in an anti-ligature cell on normal
location, the man had cut his arms using a piece of plastic which he broke off
his bed. Though the injuries were not severe, concerns that the man might do
serious harm to himself were raised. As a result, he was moved to a cell
covered by CCTV in the Care and Control Unit (CCU). (The use of such a cell
does not necessarily mean that he was observed constantly, but it would
provide the facility for remote monitoring.)
28. As mentioned above, open ACCT documents are subject to regular review.
On 26 July, the day after the man moved to the CCU, his document was
reviewed with the level of risk identified as ‘raised’. The review document,
completed by the SO, stated: “the man still bitterly depressed though
somewhat better than yesterday. Still wishes to kill himself and would do so if
the means were available.” A decision was taken that the man would remain
in the camera cell, subject to hourly observations, until he was assessed by
the mental heath team.
29. A mental health assessment was conducted by a registered mental health
nurse, on 28 July, four days after the man’s reception into Portland and three
days after he harmed himself. He recorded the following in the man’s ongoing
record:
“Poor eye contact, low voice tone, slowed rate and rhythm. Poor posture.
Palate has been affected. Sleep poor, vivid dreams. Strong family history
of depression. Assessed to be high risk of both self-harm and suicide. To
remain in CCU with hourly observations.”
30. The registered mental health nurse also wrote that caution would be needed
when prescribing any medication given the family history of misuse and the
man’s low mood.
31. On the same day, a further review of the ACCT document was carried out,
stating that the man had declined food, exercise and showers, and continued
to ask for a razor blade. Later the same day, a note in the ongoing record
stated that the man continued to bang his head against the wall of his cell.
32. Over the next few days, the man remained in the CCU cell and, although the
ACCT reviews recorded some improvement in his general demeanour,
concerns remained about the possibility of attempted suicide. The nurse saw
the man on 29 and 30 July, and on 1, 2 and 4 August. Although he noted
some improvement in the man’s mood, he wrote in the clinical record that he
remained at high risk of self-harm and suicide.
33. The man’s offender supervisor at Portland first saw him on 30 July in the CCU
cell. She wrote in the Offender Management Unit (OMU) contact sheet that
Final Report: 12
Date: September 2010
she had seen him for an hour and that, for the first 35 minutes, he did not
speak and barely acknowledged her presence. The offender supervisor
reported that after that time, the man did start to talk to her, though it was
“tough going”.
34. On 4 August a nurse saw the man and wrote in the clinical record that he felt
worse and was suicidal all the time. On the same day, during the sixth review
of his ACCT document, the prospect of moving him to the Coping Skills Unit
was raised. Whilst the man understood that it was not appropriate for him to
remain on the CCU indefinitely, he was apprehensive about moving. This
was made clear by a Security Information Report (SIR) four days later, on 8
August, in which the offender supervisor wrote:
“Whilst interviewing the man on 06/08/08 in the CCU, he mentioned that
he might be transferred to Collingwood [the Coping Skills Unit] on
08/08/08. If this did happen he said he would find something with which to
harm himself and also that he would attack someone else. This was not
said in a threatening manner nor did he say it was a plan or intentional. It
was more that he would have ‘thoughts’ that he couldn’t control in a busy
environment and that he would act on them. He said he wanted to stay in
the CCU as he was left alone and could control his thoughts in isolation.”
35. The offender supervisor recorded similar concerns after seeing the man on 8
August. She wrote in the OMU log that:
“He is due to move to Collingwood [on] Friday 8/8. I believe, and he says,
if he does he will harm himself and assault someone. He says this is not
intentional but when he is in a crowded place he gets thoughts which he
cannot control.”
36. Despite these concerns, the man was moved to Collingwood unit on 8 August
and located in a gated cell to facilitate observation by staff. Later the same
evening, it was discovered that he had made numerous scratches to his left
forearm using a radio aerial. As a result, he was moved back to the CCU.
The following day, he was seen by the registered mental health nurse who
completed a mental health assessment and stated that Levi’s mood seemed
to have improved. The nurse recommended that the man should return to the
Collingwood unit with observations every half-hour. His cell was to contain
nothing that he could use to harm himself. This was also discussed in an
ACCT review, during which the man was unable to explain why he had cut his
arm the previous day. The man then went back to the Collingwood unit in
what constituted his third move in a 24 hour period.
37. Shortly after the man’s move to the Collingwood unit, an officer wrote the
following entry in his ongoing record:
“Had a chat with the man to see if he wanted to come out and associate
but he declined. I asked how he was and explained that it sometimes
helps to talk to people. He said it wasn’t being in prison that made him
feel depressed as he was like it on the out. I asked what sort of things
Final Report: 13
Date: September 2010
help with his mood and he said playing music. He has asked for a guitar
to be authorised by a governor. I did explain that I wasn’t sure if this would
be possible whilst he was on high levels of observation. We discussed
moving to Beaufort on Monday and I explained the music facilities to him,
and he seemed to brighten up a little. I have changed one of the TV
channels to TMF [a music video station] as he said music helps him to chill
out.”
38. It appears, therefore, that the man’s move to the Collingwood unit was
intended as an interim arrangement, with the ultimate aim being a return to a
normal residential unit. It also seems that the Beaufort unit had facilities that
might prove conducive to an improvement in the man’s state of mind. Indeed,
the ACCT review that took place on 11 August discussed his enjoyment of
music and the possible move to the Beaufort unit. The man moved to this unit
on the same day.
39. The nurse saw the man on 18 August and reported a definite improvement.
He wrote in the clinical record:
“Voice tone rate and rhythm nearly back to audible levels. Diet improved.
Personal hygiene a massive improvement, full self-care noted and
appears to be much less depressed. Undertook his first music session
today and has … a few friends on the wing that … he feels he can connect
to.”
40. An ACCT review (the tenth) conducted the same day – a week after the man’s
move – reported that he felt settled on the wing and enjoyed spending time in
the music room. The man said he always thought of harming himself but, at
that time, did not feel the need to act on them. Although his risk was now
identified as ‘low’, members of staff at the review meeting decided to keep the
ACCT document open.
41. Over the following week, the entries in the man’s ongoing record appeared
much more positive than those made previously. The man was reported to be
spending much of his time in the unit’s music room and had been playing in a
band as well as rehearsing for a talent show. He was apparently engaging
with members of staff more frequently, enjoying watching the Olympic Games
on television, and chatting with officers about cooking and recipes. This was
reflected in his ACCT review, which reported that he was eating properly, was
settled on the unit, and was finding solace through music. Despite this, he
was still very concerned about his relationship with his mother, and could not
guarantee that he would refrain from self-harm in the future.
42. Further ACCT reviews were conducted on 1 and 9 September, and both were
largely positive in nature. On 2 September, he gained employment as a
library officer, and on 11 September took part in the unit talent show. The
documentation appears to indicate that the man was making progress in
terms of his general demeanour and state of mind.
Final Report: 14
Date: September 2010
43. On 16 September, the 14th review of the ACCT document was carried out,
and a decision was taken to close the document. The review form stated: the
man has shown no signs of self-harm and communicates well with staff.
Loves the music room, and attends all activities allocated.” (It appears that
nobody from the healthcare or mental health teams were present during this
review.)
44. On 22 September, the man saw the nurse for a mental health review. He
wrote that the man had made “massive improvements in his socialisation and
articulation but finds himself returning to negative ways”. His mood still
appeared low but he did not report any thoughts of harming himself. The
nurse wrote that he had consulted the doctor and had decided to prescribe
anti-depressants for the man for a trial period of six weeks. This was to
attempt to stabilise his mood and decrease the number of low points that he
was experiencing. A daily dose of 20mg Fluoxetine was prescribed.
45. When an ACCT document is closed, a post-closure review should be
scheduled for a future date. The purpose of the review is to examine the
decision to end the ACCT support in light of the prisoner’s behaviour in the
interim period, and decide whether it should remain closed or be re-opened.
In this case, a post-closure review took place on 23 September, which
reported that Levi felt settled, enjoyed music, and liked to be kept busy. He
had experienced no recent thoughts of self-harm. The ACCT document
therefore remained closed.
46. The nurse saw the man for a mental health review on 1 October. He noted
that the man was flat in mood and “on his self-confessed downward spiral”.
He discussed the man’s medication with him, and noted that he was tolerating
his anti-depressants well with no side effects. The man requested a stronger
dose, although this was not given at the time. The nurse saw the man again
the following day because he appeared miserable and had a poor outlook on
life. He noted in the clinical record that the MHIT would remain involved with
the man and would continue to monitor him on a regular basis.
47. On the morning of 4 October, a further ACCT document was opened. An
officer wrote on the Concern and Keep Safe form that the man had told him
he felt like “slitting his wrists or neck”. He could not identify a particular cause
for his feelings and could not concentrate on his usual coping mechanisms
such as music. The man had surrendered his razor to the officer upon
request. In an assessment interview two hours later, the man told an officer
that he had felt like cutting himself the previous evening, and did not care
whether he lived or died. He mentioned that he had suffered from depression
since the age of 15, and that on a scale of 1-10 (1 being the lowest) he was a
two. The man said he constantly thought about unresolved family problems,
and recurring nightmares relating to gang membership when he was younger.
48. Following the assessment interview, the man met a Senior Officer (SO), an
officer, and somebody from the healthcare team, in order to look at what
further action would be taken. It was mentioned that the man had recently
started a new course of anti-depressants but would not feel the benefit for a
Final Report: 15
Date: September 2010
few weeks. A decision was taken for the man to remain in his cell rather than
move to an anti-ligature cell, given that his thoughts were about cutting
himself rather than hanging. Somebody from healthcare advised that the man
should be observed every 15 minutes, and reviewed in 24 hours. She also
suggested different ways of keeping him occupied in his cell, such as allowing
him to have a guitar.
49. Despite the decisions taken at this meeting, the man was moved to an anti-
ligature cell on the Collingwood unit. A review the same evening stated that
the man remained unhappy. A further review took place the following
morning, when he reported feeling happier and said he had slept relatively
well. He was keen to move back to the normal residential location where
there were activities to help alleviate his depression. It was agreed that the
man would move back to Beaufort unit and be subject to hourly observations
throughout the day, and half-hourly observations at night.
50. On the same evening, after the man went back to Beaufort unit, a note was
made in his ongoing record stating: “Went into his cell to speak to him, says
he is having one of his depressed moods. An officer and myself spoke to him
at length. Gave him a stereo system and he chose some CDs from the wing
collection. Seemed to cheer up a bit and at least had a smile on his face
when we left.”
51. On 7 October, a nurse discussed the man’s case with a doctor and said he
had displayed possible symptoms of serotonin syndrome (an adverse reaction
that can occur in response to some types of anti-depressants). Fluoxetine
was no longer thought to be an appropriate treatment, and so the man was
prescribed Diazepam instead.
52. Although reports in the man’s ongoing record suggested an improvement over
the next two days, he rang his cell bell on 8 October to say that he was very
unhappy. He declined the offer of speaking to the Samaritans by telephone,
and also said he did not want to see a Listener (a trusted prisoner trained by
the Samaritans). The man explained to an officer that he had recurring
nightmares about his friend being shot dead, something he had witnessed
when he was younger.
53. On 10 October, a note was made in the man’s ongoing record that he
remained depressed. He had been given a guitar so that he was able to play
music in his cell, and his door had been left open so that he could see unit
staff whenever he wanted to. Two days later, the man appeared so low in
mood that unit staff felt it was necessary to move him to an anti-ligature cell
on the Collingwood unit. He returned to Beaufort unit the following morning
and a note in his ongoing record stated, “I have phoned healthcare and
requested as a matter of high importance that the man is seen by someone as
his mood is so very low and of great concern.” It appears that unit staff
remained worried about his state of mind but felt they were limited in the
actions they could take to alleviate his depression.
Final Report: 16
Date: September 2010
54. The man saw a doctor on 13 October, and he was prescribed a 70mg daily
dose of Lofepramine, an anti-depressant which works in a different way to the
previous medication. The following day a nurse wrote in the clinical record
that the man still needed to see him and the doctor to discuss a second anti-
depressant.
55. Reports indicate that the man’s mood was prone to rapid and severe
fluctuation. For instance, during the ACCT review on 14 October he was
described as “in a very good mood”. However the following day a nurse
conducted an assessment and found him to have “flat mood, poor eye contact
and rapport, with hopelessness and poor coping strategies”. On 16 October,
an officer noted that he was unable to see the man when conducting the roll
check. He went into the cell and found him sitting on the bathroom floor,
clutching his knees.
56. Also on 16 October, the nurse saw the man for a mental health review. He
wrote in the clinical record that the man had been asking for a guitar as a form
of stimulation but was not allowed it as staff members feared he would use it
to attempt suicide. The nurse wrote that he thought the guitar would be
therapeutic and advised unit staff against such negative thinking. However,
he found the following day that he had not been allowed the guitar.
57. The man’s change in demeanour continued over the next few days. On 17
and 19 October, he was reported to be joking with unit staff and talking about
guitar instruction, and during his ACCT review on 21 October was described
as feeling good. From 20 October he was allowed to use a guitar in his cell,
he was about to start teaching guitar to other prisoners, had begun library
orderly training, and was soon to start writing music for the unit pantomime.
However, on 23 October, the man rang his cell alarm to report that he was
depressed and felt like ‘doing something’ (meaning harming himself).
58. The man’s mood appeared to improve over the next two weeks, with reports
in his ongoing record largely positive. A seemingly brief ACCT review on 5
November stated only that he felt worse at the weekends but did not know
why, and no change was made to his observation levels. A week later, an
ACCT review chaired by an SO and attended by the nurse, reported that the
man was much happier, was engaged in “purposeful activity” (work, education
or other organised activity), and was responding to his medication. They
decided to close the ACCT document.
59. Three days later, on 15 November, the man pressed his cell alarm and the
officers who attended discovered severe burns on his left arm. As some
officers monitored him whilst others returned to the unit office to alert
healthcare staff and the orderly officer, the man produced a cigarette lighter
and attempted to harm himself again. The lighter was removed and he was
restrained. He cooperated and was taken to the healthcare centre to have his
injuries treated.
60. An ACCT document was opened and the man was moved to the Collingwood
unit where he was subject to constant observation. In his assessment
Final Report: 17
Date: September 2010
interview on 16 November, the man said his depression was “like a switch”.
He had felt okay the previous morning but very low by lunchtime. He
described the act of self-harm as a form of sensation in order to provoke
feeling and release his low mood. When asked to place himself on the scale
of 1-10 (one being worst, ten being best), the man responded with a firm one.
Prior to his depression increasing, he had been eating, sleeping and
associating well. The man was keen to return to Beaufort unit; he said he
found the regime enjoyable and the unit staff supportive.
61. During the first ACCT case review on 17 November, the man appeared to be
in higher spirits and quite chatty. The review was attended by a Governor,
Principle Officer (PO), an officer and somebody from healthcare. The man
and the staff discussed his act of self-harm, particularly why he did not inform
unit staff until after he had burned himself. It was reported that he needed to
be encouraged into activities to occupy his time, and that unit staff were
aware of this and would work with him. The ACCT observations were
changed from constant to hourly. On the same day, the man moved back to
Beaufort unit, with an officer describing him as quite jovial at that time.
62. Three ACCT reviews were held between 18 November and 3 December, all of
which were generally positive in nature. Also on 18 November, a clinical
decision was taken to re-refer the man to the MHIT. Until that point, he had
been seen very regularly by the nurse, but was not part of the MHIT caseload.
The man’s medication was also increased to 140mg in the morning and 70mg
at night.
63. On 24 November, the offender supervisor and the man held a telephone
conference with his offender manager (a probation officer based in the
community). They discussed his accommodation arrangements and licence
conditions for his release. He said he preferred not to return to his mother’s
home due to the difficult nature of their relationship. He mentioned moving to
Leicester to be closer to his brother, but this was a thought rather than a
specific plan. Three days later, the offender supervisor again met the man
and discussed his release arrangements. She reported in the OMU log that
the man was happy to live in a probation approved premises.
64. The decision to close the man’s ACCT document was made on 3 December,
and a post-closure review conducted on 11 December. The man said he
would approach members of staff if he started to feel very unhappy. On the
same day, a mental health nurse in Portland’s MHIT, completed a detailed
mental health assessment. During the interview, the man told the nurse that
he felt positive about his future. In terms of the risk of self-harm, she wrote:
“The man has a history of self-harm and/or attempted suicide. He self-
reports that these are not planned but are impulsive. He is in a high risk
age group for successful suicide and therefore, although the risk is
currently low, this will increase if his mental state begins to deteriorate.”
Final Report: 18
Date: September 2010
65. A nurse wrote that, if the man were to remain in custody, she would continue
to see him for ongoing assessment. She acknowledged, however, that he
would soon be released.
66. On 15 December, the offender supervisor met the man to discuss his release
arrangements. The man said he wanted to stay in Dorset after release to
make a new start. The offender supervisor was concerned that, because the
man did not know anyone in the area, he might isolate himself. However, by
18 December the man had made the decision to stay in Weymouth. In
practical terms, this was useful because the offender manager was struggling
to find appropriate accommodation for him in the London area.
67. The man was released from custody on 6 January 2009, his automatic
release date. (Prisoners are usually released at the halfway point of their
sentence, and serve the second half of the sentence in the community under
the supervision of an offender manager and whilst subject to licence
conditions.) The man’s sentence expiry date was 7 October 2009. He had a
prescription for 70mg Lofepramine at the time of his release. In addition to
the standard licence conditions and two further conditions which related to
him refraining from contacting the victim of his offence, the man was also
required to reside at a probation approved premises. (Approved premises are
hostels run by the probation area of the National Offender Management
Service. They provide additional monitoring and support for people upon their
release from prison.)
68. It is usual practice for prisoners to be released into an approved premises in
their home area. Regular appointments with an offender manager, usually a
probation officer based in the same area though not in the approved premises
follow. In the man’s case, and somewhat unusually, his licence required him
to reside at Weston approved premises in Weymouth, Dorset, whilst his
supervising probation officer was based in central London, some 140 miles
away.
69. On 20 November 2009, my investigator met with the offender manager to
discuss these unorthodox arrangements. She explained that, prior to the
man’s release; he had said that he did not want to return to live with his
mother. The offender manager was unable to secure appropriate
accommodation for him before his release date, and so offender supervisor
located the approved premises in Weymouth as a temporary arrangement.
70. This was, undoubtedly, not an ideal arrangement though it was thought more
beneficial to the man’s progress in the community to the alternative of being
released without a place to live. Being located so far away, it was not feasible
for the offender manager to keep face to face appointments with the man,
although she did speak to him by telephone and received daily progress
reports from approved premises staff.
71. The man had in fact expressed a wish to stay in the Dorset area, rather than
return to London some three weeks prior to his release from Portland. At this
time, the offender manager attempted to transfer his case, though Dorset
Final Report: 19
Date: September 2010
Probation Area refused to accept him for supervision. This led to the
arrangement in question, whereby the man was located in Dorset on a
temporary basis but supervised by a probation officer based in London. The
offender manager explained that she continued to look for suitable
accommodation for him in London but, on 15 January, he told her that he
wanted to relocate to Leicester to be nearer to his brother. The offender
manager began to liaise with Leicestershire and Rutland Probation Trust with
a view to transferring him to an approved premises in the area, and for his
supervision to be managed by a local office. Before this could happen, the
man was returned to custody for breaching the terms of his licence.
72. Regarding the breach of licence, the man failed to remain in his room at the
approved premises when instructed, after a fight broke out between two other
residents on the night of 18 January. He then left the premises at 12.30am on
19 January – outside the curfew time – and returned, intoxicated, at 4.45am.
The man was subsequently arrested by the police on suspicion of assault
during the time that he was absent from the approved premises.
73. On the advice of the senior probation officer based in the approved premises,
paperwork was sent to the Release and Recall Section of NOMS requesting
revocation of the man’s licence. The licence was revoked by the Secretary of
State for Justice on 20 January. The following day, 15 days after his release
from Portland, he was returned to custody. He was imprisoned at HMP
Dorchester for one week before transferring to Portland on 28 January. On
the same day, he was prescribed 70mg Lofepramine.
74. When transferred to Portland, the man originally went back to the Beaufort
unit, where he had spent much of his time prior to release. On 2 February,
the offender supervisor wrote the following in his OMU record:
“Spoke to a SO on Beaufort wing. I was a little concerned that the man
went straight back to Beaufort when he came back, I felt he should have
gone through the normal channels and gone to a normal wing. I feel going
back to Beaufort will not change anything or teach him anything. The SO
felt the same and is going to arrange move.”
75. When the offender supervisor next saw the man on 11 February, he was on
the Drake unit after leaving the Beaufort unit. Throughout much of February,
the man appears to have lived at Portland without incident and certainly he
was not subject to the ACCT process. On 16 February, the Parole Board
notified him that he would not be re-released before the end of his sentence.
The document stated:
“The panel was concerned that the man had breached licence conditions
very shortly after release and that there were allegations of a new violent
offence being committed. Although having only one conviction on his
record the apparent commission of a further offence so soon after release,
together with the use of alcohol and the apparent wilful breach of hostel
conditions led the panel to the conclusion that risk was not manageable in
Final Report: 20
Date: September 2010
the community currently. Accordingly no recommendation was made as to
release.”
76. This decision meant that the man would remain in custody until his sentence
end date of 7 October.
77. On 21 February, the man was assaulted by other prisoners on Drake unit. A
officer reported in a Security Intelligence Report (SIR) that the man had
“sustained numerous facial injuries with one eye already closing”. The injury
was discovered when another officer unlocked his cell in order that he could
collect his medication. An officer noted that, although Levi claimed to have
tripped on the stairs during association, it was his belief that Levi had been
assaulted, possibly in his cell. As a result of an investigation into the incident,
sanctions were taken against three other prisoners.
78. Notes in the man’s clinical record describe him having “sustained an injury to
his left eye, this was very bruised and swollen, he also had a bloodied nose
and several marks around the left area of his face”. The man was treated for
his injuries at Dorchester Hospital. His condition was described simply as a
“facial injury” and he was prescribed pain relief medication. When he returned
to Portland, the man was moved to the Grenville unit and then, on 23
February, to the Nelson unit. On the same day, the man used a lighter to
burn his left arm over the previous burns. An ACCT document was opened.
An officer noted on the Concern and Keep Safe form that the man had told
him it was the worst he had ever felt and he wanted to die. After treatment in
the healthcare centre, he was relocated to the Collingwood unit. However, it
appears that clear instructions about the man’s needs were not immediately
given to unit staff, as an officer stated in the ongoing record:
”Received no instruction as to what to do with the man so rang healthcare.
He was to be housed in 1-12 with an anti-rip blanket and an anti-rip gown.
He also has socks and slippers. This is all he is to have until he is
reviewed tomorrow.”
79. Also on 23 February, the man saw a doctor, who noted his physical injuries
from the assault and the self-inflicted burning of his arm. She increased his
dose of Lofepramine to 140mg in the morning and 70mg in the evening. The
man had previously been prescribed this dose, but it had been reduced prior
to his release from custody.
80. The man attended hospital on 24 February for the treatment of injuries
relating to the assault on three days earlier. His right wrist felt tender and an
X-ray was performed. The wrist was not broken and a diagnosis of soft tissue
injury was given. The man was also referred to an ophthalmologist for injuries
sustained to his eyes. An appointment was made for 10 March.
81. Also on 24 February, an assessment interview was completed which detailed
the man’s long history of depression and the previous incidents of self-harm.
It did not specifically mention the possibility of the assault as a trigger for the
latest incident, though it did acknowledge that the man felt as if he was in a
Final Report: 21
Date: September 2010
“dark cloud of depression”. The man mentioned that he had previously spent
time teaching guitar on the Beaufort unit. He said he would like to move back
to the state he was in just before release, when he was playing and teaching
music on this unit.
82. Shortly afterwards, the Action Following Assessment form was completed,
and stated that the man’s urge to self-harm had fallen significantly from the
previous day. It was also recorded that he had expressed a strong desire to
return to the Beaufort unit, for which a referral had been made. The
Immediate Action Plan recorded that the man was to be observed constantly,
and was not to be left with a lighter in his cell. He was assessed as a high
risk on the cell sharing risk assessment (CSRA) due to the nature of his self-
harm.
83. It is clear that members of staff on the Nelson unit remained very concerned
about the man, and about their ability to manage his needs appropriately. On
25 February, an officer wrote the following in the man’s ongoing record:
“Had a long chat with the man. I have serious concerns about his well-
being. The man is in a very low depressive trough at the moment. He has
no motivation at all and says that on top of that he has really had his self-
confidence knocked by the assault on Drake [unit]. He didn’t want a
shower or for me to walk him to the library. He says he can only see the
situation remaining the same when he is released. He does however have
family (brother) support when he is released, but at the moment sees only
negative things. Nelson is a very busy working [unit] and I am worried that
we will not give him our full attention or we just do not have the resources
to deal with a complex medical diagnosis. There appear to be issues with
him going back to Beaufort. However I feel the man’s situation far
outweighs those issues and we have a duty to offer him the best care we
can physically provide.”
84. There is no indication that any direct action was taken as a result of an
officer’s entry in the ongoing record, and it is unclear whether he raised his
concerns directly with other members of staff.
85. As with the man’s previous time in custody, he experienced fluctuations in his
mood. At his ACCT review on 27 February, the man reported feeling
somewhat better. A positive move was that he handed a razor blade from his
cell to unit staff. However, on the following day the man went to the
healthcare centre and confided in staff that he could not trust himself to refrain
from harming himself. At this time, a decision was taken to relocate him to the
Collingwood unit.
86. On 27 February, the man was told during his ACCT review that Beaufort unit
was unwilling to accept him back. My investigator spoke to, the senior officer
for Beaufort unit, about the criteria for accepting prisoners. The SO explained
that when prisoners who have previously spent time on the Beaufort unit are
recalled to custody, they are often returned to the unit by default. This is what
happened to the man when he returned to prison. However, if members of
Final Report: 22
Date: September 2010
unit staff feel that there is little further progress that can be made with a
particular prisoner and the place can be better utilised by someone else, then
that prisoner will be returned to a normal residential unit. This was the case
with the man. Although his experience on the Beaufort unit had been largely
positive, the unit staff members felt that he would not benefit from being on
the unit any more than he would on a standard unit. For this reason, the man
was moved to the Drake unit and was not accepted back to Beaufort.
87. During case reviews held on the Collingwood unit, the man’s state of mind
continued to fluctuate, though he was mostly depressed and remained subject
to constant ACCT observations. It appears that officers on the unit attempted
to engage him in some activity, for example, on 1 and 2 March he was
allowed to walk around the grounds with an officer. The man continued to ask
about returning to the Beaufort unit and continuing his music lessons, but was
told that this would not be possible.
88. On 3 March, the man returned to the Nelson unit but remained miserable.
The same day he was reported to be very low and a cause for concern to
staff. On 4 March he was withdrawn and not very talkative, and two days later
described as “very flat”. On 9 March, an officer made another detailed entry
in the man’s ongoing record, stating:
“Having spent much more time with the man now, I feel that he is in quite a
good place mentally at the moment. He has built up quite a good trust of
some members of staff on Nelson and is quite open and honest about his
emotions now. He speaks often about where he feels he is at on a scale
of 1-10. The man is still very fragile and I am aware that at any time he
may rapidly deteriorate, however now I know him better I can spot some of
the signs when he goes downhill. He is eating, although not a great deal.
He reads and attends library now. We are getting the man out and about
as much as possible and he is very polite and well-mannered. After some
discussion with offender supervisor and a governor it has been decided
the man cannot go back to Beaufort. He seems happy here but I am not
convinced it is the best and safest place for him.”
89. As with the previous entry, it appears that the officer was keen to ensure that
the man was appropriately cared for, but was unsure that a normal residential
location was the right place for this to be provided. Provision was, however,
made for the man to have a guitar in his cell for certain periods.
90. On 10 March, the man attended a hospital appointment with the
ophthalmologist. This was a follow-up appointment after he was assaulted 17
days earlier. No further treatment was required, and the man was discharged.
91. The next day, the officer made another entry in the ongoing record, stating
that the man enjoyed music and was happy to have been given the guitar.
Five days later, at the 12th review of his ACCT document, the man reported
feeling very low in mood. Although he said he did not feel like harming
himself and did not want to go to the Collingwood unit, (which provided a
better facility for constant observation) a decision was taken to move him
Final Report: 23
Date: September 2010
there and place him on constant observation. The following day – 17 March –
after a further review, the man moved back to the Nelson unit and subject to
half-hourly observations.
92. During an ACCT review held on 19 March, the man was told that he could not
return to Beaufort unit but that he might be able to transfer to Feltham.
However, the man said he did not want to go to Feltham and would rather
stay on the Nelson unit at Portland. The following day, a note regarding this
issue was made in his ongoing record by an SO, who stated:
“Spoke to the man ref his transfer concerns. He was under the impression
that a transfer to Feltham would put him on the poor coping skills unit
where he would not get the help he knows he needs. I explained to him
that even if he was put on that wing initially he would have a very good
chance of getting a place on the unit he needs, a far better chance than if
he stayed here. This he appeared to accept wholly.”
93. It is clear that, with no inpatient medical facilities, wing staff were concerned
that Portland was not the most appropriate place for the man, and that
Feltham would be able to offer a more suitable regime. Indeed, on 23 March,
the man was told by the officer that he would be moving to Feltham the
following day. The officer wrote that he had a positive chat with the man
about the benefits of being in a dedicated healthcare unit and the proactive
help that he would get regarding his depression and paranoia. An SO also
noted that the man was positive about the move and realised that the help he
needed would now be available to him.
Transfer to HMP Feltham
94. The man transferred to Feltham on 24 March, where the usual reception
process, including a CSRA, was completed. He was initially placed on the
Kingfisher unit. An ACCT review took place on the day of the man’s arrival,
during which the man said he was low in mood and had been told he was
transferring to Feltham in order to be located on Lapwing (the inpatient
healthcare unit). An SO recorded that this was not what was portrayed by
Portland in advance of the transfer to Feltham, and he would have to be
assessed for suitability. The man explained that his mood was never positive
and that he would like full support from the healthcare team.
95. Several conversations between the man and various officers are recorded on
25 March. During each conversation he appeared anxious about whether or
not he would be transferred to the Lapwing unit. When told that he would
need to be assessed by the Community Mental Health Team (CMHT) and
was not guaranteed a place, the man expressed his belief that staff at
Portland had lied to him. He felt they had used the prospect of Lapwing to
transfer him out. The man also said he had formulated a plan to kill himself
by obtaining a razor blade from another prisoner and cutting his wrists.
96. On the same day, the man was seen by somebody from the CMHT. He told
her that he had been diagnosed with bipolar disorder. He was able to
Final Report: 24
Date: September 2010
describe how he came to feel depressed but could not identify particular
triggers. The man said he had no motivation to do anything and felt hopeless.
He said he had thought about different ways to kill himself but had no specific
plan.
97. In the evening of the same day, an officer made a note in the ongoing record,
documenting a conversation he had with the man. The officer wrote that the
CMHT had said that the man did not fit their criteria, though it is not clear
whether or not he passed this information on to the man. An officer said that,
as the man had now formulated a plan to take his own life, unit staff were
extremely concerned for his well-being. The entry also mentioned that the
man was due to be transferred to HMP Rochester two days later, but that the
officer had decided not to tell the man as it might worsen his situation.
98. The following day, 26 March, the man continued to tell staff of his plan to
obtain a razor blade from another prisoner. An SIR was raised in relation to
this. It was agreed that other prisoners would be searched when the man was
out on association and he would be subject to a full search following any
activity that brought him into contact with other prisoners. Unsurprisingly, the
man declined association shortly afterwards, saying he did not care to
socialise.
99. An ACCT review took place the same afternoon. The review form in its
entirety reads: “The man has been informed that he will not be going to
Lapwing and he will be going to Glen Parva at the earliest opportunity. The
man accepted what he was told and will be seen again tomorrow.” This would
almost certainly have been unwelcome news for the man, who had arrived at
Feltham only two days earlier having been told more than once that Feltham
would be better able to meet his mental health needs.
100. Despite the decision to move him from Feltham almost as soon as he had
arrived, he appeared to adapt quite well. During reviews on 27 and 30 March
(neither of which appear to have been attended by any discipline staff) the
man appeared positive about the move, which would find him in close
proximity to his brother, who lived in Leicester. A note in the man’s wing
history sheet on 30 March records that he asked to go to a vulnerable
prisoner unit at Glen Parva for his own safety and because he felt they would
have more time for his needs. (No such unit exists at the prison, although
there is no evidence that the man was told this at the time.)
101. At 4.30pm on 30 March, an outreach worker based in Feltham’s Safer
Custody office, noted the following in the man’s ongoing record:
“The man has now been told that he will not be going to Glen Parva in the
foreseeable future. He didn’t say anything, he just hung his head and
asked for a light. I asked if he wanted his evening meal – this he
declined.” At 5.35pm, a further entry was made, again by the outreach
worker, this time stating: “The man has now been told he will be going to
the prison in the morning – he is happy with the decision.”
Final Report: 25
Date: September 2010
Transfer to HMYOI Glen Parva
102. The man was indeed transferred to Glen Parva on the morning of 31 March,
eight days after, he was transferred from Portland to Feltham. The man was
assessed as posing a medium risk on the CSRA, which also stated that he
had bipolar disorder and liked to be alone when he felt low in mood. A note in
his ongoing record on the same day also stated that the man had bipolar
disorder, though there is no record of an official diagnosis.
103. On the same day, the man saw a psychiatrist, for a detailed assessment. He
wrote in the clinical record that the man felt very low and had thoughts of
killing himself. In addition, he said the man always felt hopeless and had no
plans for the future. The psychiatrist wrote that the plan was for the man to
continue taking Lofepramine, which he had been prescribed before arriving at
the prison. He was also to have regular reviews by nurses working in the
prison.
104. On 1 April, an ACCT review was conducted. The document had been opened
in February at Portland, and this was its 20th review. Having arrived at the
prison the previous day, the man was residing on the induction unit. An SO
reported that the man presented as a very mature and talkative young man.
The following day, a mental health nurse, saw him for mental health support.
She wrote in his clinical record that he had settled well but still struggled with
his mood. The nurse saw the man again on 6 April and wrote that he was
getting on well with his cellmate and would like to continue sharing a cell with
him.
105. The following day, 7 April, the man again saw the psychiatrist, and reported
good days and bad days. He said he still felt suicidal at times, but in general
was feeling better than before. However, the man felt he was not getting
enough benefit from the Lofepramine. The psychologist decided to change
the man’s medication to 30mg of Mirtazapine (a different anti-depressant),
from 14 April.
106. Also on 7 April, the man moved from the induction unit to Unit 1, a standard
residential unit. He had shared his cell with another prisoner whilst on the
induction unit. As the two prisoners appeared to get on well, a decision was
made to move them to a residential unit together. A note in the man’s
ongoing record made by a Unit 1 senior officer stated that he would remain a
medium risk until a further review in May, and that the man was happy to
continue sharing a cell.
107. On the day of his arrival on Unit 1, an officer wrote in the man’s ongoing
record: “The man seems fairly settled, introduced myself as his personal
officer. Seemed in good spirits and was happy to be padded up with another
prisoner. No issues to report.” An ACCT review was conducted on 8 April,
which identified the man’s risk as low. An SO, chairing the review, stated that
the man was happier in the Midlands as he was nearer to his brother, and that
he wished to relocate in the area upon release.
Final Report: 26
Date: September 2010
108. During her interview with my investigator, a Unit 1 officer, described the man’s
presentation when he arrived on the unit differently, saying he was “very quiet,
very withdrawn … he didn’t interact with any of the prisoners, he didn’t come
out of his cell even for showering or changing his clothes”. The officer said
the man’s demeanour was a cause for concern and that, as with any other
such prisoner, officers tried to build a relationship with him. Two other Unit 1
officers, recalled the man respectively as someone who was quiet and slept a
lot, and a shy but not vulnerable prisoner. One of the senior officers in charge
of Unit 1, described the man as very quiet when he arrived on the unit, but
said he made progress as time went on.
109. Between 8 and 15 April, no particular concerns were identified in the ongoing
record. The man appeared to be getting on well with his cellmate, was
associating with other prisoners, and was not causing any problems or
concerns for staff. A Unit 1 officer talked during interview about the way in
which the man responded to attempts that were made to build rapport.
Indeed, she wrote in the ongoing record on 11 April that Levi was “out on
morning association, very vocal, laughing and joking with a large group of
peers, interacting well with unit staff and appears settled”.
110. An ACCT review took place on 15 April, chaired by an SO and attended by
two officers. During the review, the man reported feeling settled on the unit.
It was noted that, although geographically closer to his brother, he was yet to
send out a visiting order. He was advised to speak to his personal officer
regarding suitable employment. The man’s risk was assessed as low, but a
decision was made for the ACCT procedures to remain in place.
111. On the following day, a note in the man’s ongoing record indicates that he
was visited by a member of the mental health team. The member of staff
indicated that, although the man denied thoughts of self-harm, he continued to
feel low in mood throughout the day. A review was to be arranged with the
psychiatrist.
112. An officer wrote in the man’s ongoing record on 21 April, stating: “Spoke to
the man today at length. Seemed settled, stated his mood was fair and
seemed happy when I told him he would be starting at workshop 3 tomorrow
morning. No issues to report.” Although this was a relatively brief entry in the
ongoing record, it seems fairly positive in nature.
113. On the same day, the man again saw the psychiatrist. He reported that his
mood had improved but he did sometimes feel low during the day. However,
he also felt anxious and fearful. No changes were made to his medication at
this time.
114. The following day, a review of the man’s ACCT document was held. The man
said that on a scale of 1-10, he felt that his mood was a five. He said that
being occupied helped him and that he had started work. In terms of
medication, the man reported no issues and said he considered it to be
working well. He also said he had sent out a visiting order to his brother. As
Final Report: 27
Date: September 2010
at the last review, the risk was identified as low but the ACCT document
remained open.
115. Over the next week, the man remained relatively settled. Entries in his
ongoing record, whilst brief, were positive. The man also received good
reports about his behaviour and attitude in the workshop, as well as the way
in which he was mixing with other prisoners. On 28 April, the man was seen
by another mental health nurse from the MHIT. She wrote in the man’s
clinical record that he displayed clear symptoms of depression and would be
taken on to the MHIT’s caseload. The nurse also wrote in the ACCT ongoing
record that he was not thinking about harming himself and did not want the
ACCT monitoring to continue. She reported that, in her clinical opinion, it
would be appropriate to close the ACCT document. The man agreed that he
would talk to unit staff about any problems and would ask to see a mental
health nurse if necessary. This meeting appears to have been a prelude to
the ACCT review held later the same day, chaired by the Unit 1 SO and
attended by a nurse. Given the previous meeting, and the fact that the man
appeared to have been settled on the unit for some time, a decision was
taken to close the ACCT document.
116. During interview, the Unit 1 SO recalled this ACCT review and said that the
man had asked a few times for the ACCT document to be closed. He said the
man was working away from the unit, was participating in association, had a
group of friends, and behaved in much the same way as any other prisoner on
the unit.
117. Five days later, on 3 May, an officer made a further brief entry into the man’s
wing history sheet, stating: “The man seems to have had an unsettled week
this week, he did not attend his workplace on two occasions. The man
himself stated he feels ok and will return to work on Tuesday. No further
issues.” Given that this was after the closure of his ACCT document,
meaning that formal reporting of observations in the document had ceased,
but prior to the post-closure review, it might have been beneficial for the
personal officer to have provided a more comprehensive entry, with the issues
given some context and discussion.
118. The post-closure review of the man’s ACCT document took place on 5 May.
The Unit 1 SO stated that he was happy for the document to remain closed,
and that “the man isn’t feeling well (ill) at the moment but expressed no cause
for concern”. In interview, the unit 1 SO explained that he had written ‘ill’ in
brackets to clarify that this related to a physical illness rather than any
concerns about the man’s mental health. During the review, the man asked
whether it would be possible for his medication to be altered, as he felt it was
making him feel drowsy too early in the evenings. A note was made in the
entry to liaise with healthcare staff in relation to this. A further post-closure
review was not deemed necessary, although no mention appears to have
been made of the unsettled week referred to by an officer in her entry in the
man’s wing history sheet. It is unclear whether this information was available
or discussed during the post-closure review.
Final Report: 28
Date: September 2010
119. On 7 May, two days after the post-closure review, a nurse saw the man and
wrote the following in his clinical record:
“Remains low in mood. Appears very pale and drawn. Low appetite,
concentration poor, gross loss of motivation, anhedonia [the failure to
derive pleasure from activities that would normally be associated with this
reaction]. Sense of hopelessness, and high levels of anxiety. Denies any
intent to self-harm. Again asking for an increase in Mirtazapine. He has
now been on 30mg for a period of three and a half weeks. Prior to this
was on 15mg. In view of this, now increased to 15mg in the morning and
30mg at tea time.”
120. During interview, a nurse said the man had been taking Mirtazapine for just
over three weeks, and he reported feeling no benefit. She therefore made the
decision to increase his medication, and decided on a split dosage because
he wanted to be able to manage his anxiety in the mornings.
121. On the same day, the nurse also made an entry in the man’s wing history
sheet stating:
“The man currently has a depressive illness which makes it difficult for him
to work. He should be allowed to not attend for at least another two
weeks. This will then be reviewed. He is receiving treatment for this.”
122. There is no indication of the overall impact that non-attendance at work might
have, and discipline staff do not appear to have looked for other constructive
activity which might have been suitable for him.
123. There was little information documented by prison officers about the man
between 7 and 27 May. The ACCT document had been closed, and so
interactions were not being recorded as frequently as had previously been the
case. There were no concerns recorded on his wing history sheet. The
nurse saw the man on 15 May and reported that, although feeling more
relaxed, he continued to isolate himself in his cell and did not leave for
association. She saw him again on 18 May and they discussed the benefit of
interacting with others, though he remained “unwilling to consider this at this
time”.
124. On 27 May, a cell sharing risk review was carried out by the Unit 1 SO and a
mental health nurse. The review stated that the man had asked for a single
cell as he was “getting more and more agitated with his bipolar issues”, and
felt he would benefit from space and time to himself. The SO recalled that the
review came about after the nurse had approached him, having spoken to the
man about the issue. The review noted the possibility of injury to the man’s
cellmate, arising from his mental health problems. The SO assessed him as
high risk for the purposes of cell sharing, and “single cell” was noted on the
form as a specific need. The SO recalled that, by the end of that day, the
man had moved from his shared cell into a single cell on the same landing.
He would still have been able to associate with his peers. The SO was clear
Final Report: 29
Date: September 2010
that the man was moved at his own request but also to alleviate his mental
health symptoms and ensure the continued safety of his cellmate.
125. A Staff Nurse at Glen Parva, recalled that on the morning of Saturday 30 May,
the man did not attend the healthcare unit to collect his medication. The
Nurse rang Unit 1 to check the reasons for this, and was told that the man had
refused to collect it. He went to healthcare on the same afternoon, when the
Staff Nurse emphasised the importance of attending twice a day as planned.
126. However, on the following day, the man did not attend either of his healthcare
appointments to collect his medication. On 1 June, he did not attend the
healthcare unit in the morning. There is no entry in the man’s clinical record
to show whether or not he received medication in the afternoon. However, an
officer recalled that, he unlocked the man’s cell at around 4.30pm to allow him
to visit the healthcare centre for his medication. The officer saw the man
sitting at the table in his cell, and asked him if he wanted to go for his
medication. The man replied no, and the officer asked if he was sure, to
which he responded yes. The officer said he was able to remember this
particular exchange because it was the last time he saw the man before his
death. Although only a brief conversation, the officer did not feel there was
any particular cause for concern at this time. He told my investigator that it
was not uncommon for prisoners to refuse their medication, which would not
necessarily indicate that a person might be at risk.
Events during the night of 1 and 2 June
127. The overnight discipline staffing of Glen Parva comprises a senior officer, two
‘roaming’ prison officers, and an officer based on each unit. The unit-based
members of staff are generally Officer Support Grades (OSGs), with the
exception of Units 2, 9 and 11, which are staffed by prison officers. Keys are
held by the senior officer and the two roaming officers only, with other officers
being confined to the unit where they are based. All members of staff,
however, possess a cell key in a sealed pouch. When prisoners are locked in
their cells overnight, the sealed cell keys can be used in an emergency if a
cell needs to be opened.
128. On the night of 1 to 2 June, an OSG, was based on Unit 1. He explained in
interview that his normal procedure is to check the unit landings every half
hour and activate an electronic sensor which logs the time when the check is
completed. Computerised reports from this system show that the sensors
were activated around every half an hour that night. The OSG went on to say
that, for prisoners not subject to ACCT monitoring, he would not necessarily
look into every cell during every check, but would look into cells at random.
He said that, as Unit 1 cells do not have privacy flaps but have an
unobstructed glass panel, it is easy to look into cells when necessary.
129. The OSG said that around 4.30am, during his routine check of the landings,
he happened to look into the man’s cell and saw what he thought was the
man standing in front of the window. He tried to engage him in conversation
and, when this failed, switched on the cell light using a switch located on the
Final Report: 30
Date: September 2010
outside. It was at this point that the nature of the situation became clear to
the OSG. He saw that the man was hanging from a ligature, fashioned from a
bed sheet that had been tied to the window bars of his cell.
130. The OSG used his radio to alert other members of staff. He recalled advising
that the situation was a ‘code blue’, indicating that someone was not
breathing, though other officers thought the initial radio message contained
only the information that assistance was required. One of the roaming officers
who was on Unit 2 at the time, said he looked at his watch when he received
the radio message and saw that it was 4.32am. The senior officer, who was
based in the administration centre, said that although the message indicated
only that assistance was required, he could tell that this was an urgent
situation from the tone of the OSG’s voice. He said that the OSG sounded
“not distressed but perhaps quite hyped up with regards this was really urgent
… he said it with a lot of urgency … and he didn’t say it once, he repeated it”.
131. A number of officers made their way to Unit 1 immediately after hearing the
radio message. Two officers’ one of which based on Unit 2 were two such
people. Both report arriving at Unit 1 only seconds after the initial message
was received. One of the officers said he ascertained the nature of the
situation from the OSG, and clarified the initial radio call with a ‘code blue’
message.
132. Meanwhile, an SO had used his radio to alert a nurse that he would collect
her from the healthcare department in order to attend Unit 1. (Healthcare staff
members do not carry keys when working overnight, and so she would require
an escort.) Given that he was based in the administration centre, directly
above the healthcare unit, the SO arrived quickly and the nurse was waiting to
be collected. They ran to Unit 1, and the SO estimated that they arrived less
than one minute after he collected the nurse.
133. The second roaming patrol officer, was based in the south corridor when he
received the call over the radio. He recalled that only seconds after the initial
message, the ‘code blue’ clarification was made. Although he acknowledged
that it was difficult to estimate, he said he arrived on Unit 1 between 60 and
90 seconds after the first radio message.
134. There was two officers arrived at Unit 1 first, followed by another office, an SO
and a nurse. The SO opened the man’s cell door. An officer explained that
there was no delay in opening the cell, and he would have used his own
sealed cell key had the SO not arrived when he did.
135. The SO and an officer entered the cell and took the man’s weight. The SO
cut the ligature with his anti-ligature knife (a standard piece of equipment
carried by all discipline staff). The officers placed the man on his back on the
floor of the cell. Based on his appearance an officer and nurse both believed
that the man had been dead for some time. The nurse said she immediately
thought that cardio pulmonary resuscitation (CPR) was not viable, but it was
nevertheless attempted. The nurse performed chest compressions as well as
mouth to nose breaths. She was unable to attempt mouth to mouth because
Final Report: 31
Date: September 2010
the man’s tongue was obstructing his airway. She also asked an officer to
collect a defibrillator (a piece of medical equipment to assess heart rhythm
and to deliver an electric shock if necessary) from the healthcare centre, as
she had not taken one with her to Unit 1.
136. An officer returned with a trolley containing medical equipment, including a
defibrillator, within a few minutes. The nurse attached the defibrillator’s pads
to the man’s chest. The machine indicated that there was no shockable
electrical rhythm and advised that manual CPR should be continued.
137. Although the SO recalled that the nurse ceased resuscitation attempts before
the arrival of the ambulance paramedics, she was adamant in interview that
she continued until the paramedics arrived. The nurse said she stopped only
to attach the defibrillator pads and then continued CPR. It is worth noting that
the SO was not present at the cell for the entire time, as he left to escort the
two paramedics into the prison. My investigator confirmed with the East
Midlands Ambulance Trust that the 999 call was received at 4.34am, and that
the ambulance arrived at the prison at 4.38am.
138. The SO said the paramedics were able to enter the prison quickly, and they
ran with him to Unit 1. Nevertheless, given the geography of the prison this
was likely to have taken at least a couple of minutes. Upon arrival at the cell,
they attached an electrocardiogram (ECG) machine to the man to check for
any signs of life. None were found. The paramedic from the East Midlands
Ambulance Trust told my investigator that their electronic dispatch system
recorded the man’s death at 5.11am. The nurse recalled that she was the last
person to leave the cell. She placed a sheet over the man, not for any
medical reasons but to afford him some respect and dignity.
139. The SO acted as a co-ordinator following the man’s death and the night
manager took responsibility for implementing Glen Parva’s contingency plan.
The OSG left the unit and an officer took over its running. An officer was
appointed to keep a log of people attending the unit. The Governor and the
duty governor arrived at the prison, and a hot debrief was held at around
7.30am. (The purpose of the hot debrief was to reflect upon the situation, talk
about the response and check on the well-being of staff.) Most of the people
involved attended the debrief, minutes of which were taken. An officer was
still in charge of Unit 1 at that time and was not able to attend, though he
spoke to the care team separately. The OSG made a statement before he left
the prison
140. At 10.00am, a governor and an officer, as well as the prison’s family liaison
officer, visited the man’s brother at his home in Leicester. He was listed as
the man’s next of kin. The man’s mother was visiting her son, and so they
were able to break the news of his death to both his mother and brother at the
same time. On the same day, a service for prisoners was held in the chapel
at Glen Parva.
Final Report: 32
Date: September 2010
141. The following day, 3 June, members of staff started to become aware of
prisoners speculating that the man had been bullied and that this might have
triggered his death. SIRs were produced by an officer and by an education
tutor, and statements taken from a number of prisoners. A principal officer
and the head of Safer Custody conducted a simple enquiry and produced a
report on 8 June. (A simple enquiry is a relatively brief and informal
investigation into a specific issue, intended to reach conclusions quickly.) The
enquiry involved a PO and a senior officer also from Safer Custody,
interviewing three prisoners who were accused of bullying the man. All three
prisoners had worked as orderlies on the Unit 1 servery prior to the man’s
death. The enquiry recommended that the prisoners were returned to normal
location, but not employed on the unit servery. There was no conclusive
finding as to whether the man had been bullied, though the prisoners in
question admitted that some altercations had taken place.
142. In addition to the issue of bullying, it was suggested in written statements
made by prisoners that, on the weekend before his death, the man had a very
obvious and recent ligature mark around his neck which members of staff
failed to notice or act upon. Furthermore, an anonymous letter sent from the
parent of a serving prisoner at Glen Parva to the Chief Inspector of Prisons,
claimed that unit staff had ridiculed the man due to his poor level of personal
hygiene. This letter also claimed that on the night of 1 to 2 June, prisoners in
nearby cells had discovered that something was wrong and had attempted in
vain to alert a member of staff to the situation. The prison's liaison officer
passed the letter to my office for investigation.
143. A memorial service for the man was held in Glen Parva’s chapel on 25 June,
to coincide with his funeral. A critical incident debrief, intended to offer
support to members of staff who were involved in the response on 2 June,
was held on 16 September.
Final Report: 33
Date: September 2010
ISSUES
Assessment, Care in Custody and Teamwork
144. The National Offender Management Service uses the ACCT process as a tool
for, amongst other things, monitoring and providing support to prisoners
identified as being at risk of self-harm or suicide. All members of staff should
receive basic ACCT training and be able to open a document, as well as
making appropriate entries in the ongoing record. Some members of staff
receive more comprehensive training to conduct assessment interviews
(something that should take place within 24 hours of an ACCT document
being opened). A trained member of staff should undertake this initial
assessment interview. Subsequent case reviews should comprise no fewer
than two members of staff and also involve the prisoner subject to the ACCT
document. These reviews should also, ideally, be multi-disciplinary. When
staff members conducting a review determine that risk has been significantly
reduced or is no longer evident, and it is felt that further intensive support and
monitoring is not required, the document can be closed. A post-closure
review should take place seven days later to confirm that risk remains
reduced. Ideally, this review should also be multi-disciplinary.
145. The man was subject to four separate ACCT documents during his custodial
sentence. The most recent was opened on 23 February 2009 at Portland,
where the initial procedures were carried out as described above. Reviews
were held very regularly, sometimes on consecutive days. On some
occasions, though not all, they were attended by members of staff from
different areas of the prison, including healthcare. During the period
immediately prior to the man’s transfer to Feltham, the reviews documented
the reasoning behind the transfer, as well as the man’s thoughts and feelings
about it. A review was held on 24 March before his departure from Portland.
146. When he was transferred to Feltham, the man remained subject to the ACCT
procedures. Reviews were held on 24 (the day of his arrival), 26, 27 and 30
March, although they do not appear to have been well attended. These
reviews also seemed less positive and supportive than those which took place
at Portland. In particular, the review on 26 March seemed to be merely an
exercise in information sharing, with the review document stating the
following:
“The man has been informed that he will not be going to Lapwing, and he
will be going to Glen Parva at the earliest opportunity. The man accepted
what he was told and will be seen again tomorrow.”
147. The man did not have an ACCT review on the day of his departure from
Feltham (31 March), although one had been held on the previous day.
Similarly, a review was not held at Glen Parva on the day of his arrival, but
was held instead on 1 April. Despite reviews having previously been held at
very frequent intervals, the man was immediately subject to a weekly review
schedule. My investigator spoke to a PO, the head of Safer Custody, by
telephone to enquire about his interpretation of the ACCT process and the
Final Report: 34
Date: September 2010
normal schedule of reviews. The PO explained that decisions about the
frequency of ACCT reviews were made on a case by case basis, and there
was no ‘standard’ reviewing schedule. He went on to say that, although some
prisoners would be reviewed weekly, others were reviewed more frequently -
in some cases daily - in accordance with their risk and need.
148. The man had moved from Portland to Feltham and then to Glen Parva over
the course of nine days. It is, therefore, likely that he felt unsettled and was
potentially vulnerable. A second review was not held until 8 April, by which
time the man had been subject to yet another move, from the induction unit at
Glen Parva to a standard residential unit. Whilst the change in review
schedule was not necessarily detrimental to the man’s care at the prison,
there is nothing to suggest that any consideration was given to facilitating
more frequent reviews, even though this had been the case at the last two
establishments.
The Safer Custody manager should remind staff that ACCT reviews
should take place according to the prisoner’s circumstances rather than
at standard intervals.
149. Although the frequency of ACCT reviews declined after the man’s arrival at
Glen Parva, the documents themselves were relatively clear about his
presentation and demeanour, whether he was coping on the unit, and any
problems he was experiencing. There was, however, little continuity in terms
of the members of staff who chaired and attended the reviews. They were not
always multi-disciplinary, and the man’s personal officer never attended.
150. Outside of the formal review process, ACCT documents include an ongoing
record. The purpose is to record meaningful interaction with the prisoner. In
many cases, a minimum frequency for daily observations and conversations
(which will differ depending on risk and need) will be stipulated on the ACCT
document, and the ongoing record should be used to note the details.
However, the ongoing record can and should be used to note all significant
interaction, even when this exceeds the minimum level of information
required.
151. The 2007 HMCIP inspection of Glen Parva noted the following with regard to
ACCT:
“Although there were regular management checks of ACCT documents,
there was little evidence that these made any difference to quality.
Documents were variable; some were satisfactory but a significant number
were not, and there was an over-reliance on process rather than quality.
Reviews and recorded observations generally took place within required
timescales. However, staff recordings were often brief observations rather
than details of interactions with prisoners. Records of conversations were
often superficial and cursory. Some entries, particularly at night, were too
predictable. Management checks tended to pick up on the quantity rather
than the quality of written entries, and were often little more than a
signature. Specialist staff who may have had a role in caring for the
Final Report: 35
Date: September 2010
prisoner rarely made written entries, and it was not always possible to get
a detailed picture of the prisoner’s overall wellbeing from the ACCT
document.”
152. My investigator had similar concerns, particularly in relation to the ongoing
record element of the ACCT document. Entries tended to be brief, often
containing only rudimentary information about the man’s day to day activity.
The entries made by the man’s personal officer were no more detailed than
any of the others, and made only at fortnightly intervals. During interview, an
officer mentioned that she had a good rapport with the man, and that she
interacted with most prisoners whenever she was on duty. She also said that
the fortnightly personal officer entries represented a summary of interactions
over the previous two weeks. In my view the entries in the man’s file are very
basic, particularly if intended to cover such an interval.
153. Although an officer said she interacted well with him, this was not readily
apparent when reading her personal officer entries. The officer explained that
there was no time specifically allocated for personal officer duties, and so this
work was accommodated around the demands of other tasks. She went on to
say that her normal daily routine would bring her into contact with prisoners,
but that finding time to document their interactions could be difficult. Glen
Parva’s personal officer policy states that prisoners should be seen at least
once every two weeks, with the contact documented in the wing history
record. The policy does not specify the level of detail needed. Officer West
therefore adhered to the requirements of the policy by writing an entry every
two weeks. Nevertheless, more substantial and meaningful notes from the
personal officer would be preferable.
154. Given that the man’s most recent ACCT document was opened at Portland
and travelled with him to Feltham and the prison, it is possible to compare the
ways in which observations were recorded at the three establishments. The
man spent only a week at Feltham and much of the documentation focused
on the confusion about whether he would be admitted to the healthcare unit or
transferred to another establishment. At Portland, a number of
comprehensive and quality entries appeared in the ongoing record,
particularly those made by the man’s personal officer. Certainly, the entries
made at Portland are useful in giving an overview of how the man felt on a
day to day basis, whereas this was not always the case at Glen Parva.
155. In addition to the concerns expressed by HMCIP regarding meaningful entries
in ACCT documents, my own most recent investigation into a death at Glen
Parva (published in draft in May 2009, and in its final form in August 2009)
highlighted deficiencies in the quality of entries. I wrote:
“Once opened, the prisoner’s ACCT document was scant in places and
there were few documented meaningful assessments of his state of mind.
Meaningful entries are an important requirement in the ACCT observation
process and ongoing record. Such entries help assess the level of risk
and indicate when risk is heightened or reduced.”
Final Report: 36
Date: September 2010
156. It is disappointing to draw attention to the same areas of concern here. Whilst
I appreciate that officers have a multitude of responsibilities and find it difficult
to allocate time to write comprehensive entries, the whole purpose of the
ongoing record is to document meaningful interactions and to provide an
overview of the prisoner. When surveying the document, I would expect to
gain an immediate insight into the prisoner subject to the ACCT process, not
only in terms of mere observations but also regarding conversations,
concerns and state of mind. This was not always the case with the
documents completed at Glen Parva.
The Governor should remind all staff to complete the ACCT document
properly, with high quality, meaningful entries.
157. Although the ongoing record was not always comprehensive, the records of
the ACCT reviews seem to provide adequate information regarding the
content of the meeting and any ongoing concerns. There was, however, little
continuity in terms of the members of staff who chaired and attended the
reviews. Nevertheless, the documents indicate that the man settled well on
Unit 1, which is consistent with the recollections of unit staff. An officer, in
particular, was able to recall that although the man was very quiet and
withdrawn when he arrived on Unit 1, significant progress was made in terms
of his integration into the regime and the way in which he interacted with
others.
158. The ACCT review on 28 April, which led to the document being closed, was
chaired by an SO. The head of Glen Parva’s mental health in-reach team
(MHIT), also attended, as did the man. No other discipline staff members
were present, though the SO recalled that he spoke to various officers prior to
the review. On the review document, he wrote:
“No prevalent issues or current issues of note, settled well for some
considerable time now on Unit 1, was himself asking to close the
document, Amanda also happy to have ACCT closed as am I and unit
staff.”
159. The nurse had become directly involved in the man’s clinical care on the
same day. Although she would not yet have had a comprehensive working
knowledge of him, she had assessed him as a mental health professional.
The SO was based on Unit 1 and would, therefore, have had day to day
contact with the man. He had also canvassed other unit staff members and
had noted their views in the review document. The man was happy for the
document to be closed, and in fact had asked whether this would be possible.
160. Based on the progress made during the man’s time on Unit 1, the multi-
disciplinary nature of the review, and the agreement of all concerned that
there was no need for him to the subject to the ACCT process, the document
was closed. This does not appear to me to have been an unreasonable
decision. Although the process is intended for those at risk of self-harm or
suicide, it is also a flexible document that should be closed when the risk is
thought to have reduced or is no longer present. The man had been on Unit 1
Final Report: 37
Date: September 2010
for three weeks, had made progress in terms of integration into the regime,
and was no longer thought to be a serious risk of harming himself.
161. Although a post-closure review was held on 5 May, this does not appear to
have been a multi-disciplinary meeting. It was chaired by the SO and also
attended by a prison officer. The man was also present but mental health
staff were not. No concerns were raised during the review, and the SO did
not think it necessary to re-open the ACCT document. It is not clear whether
either of the officers read the man’s wing history sheet for the period between
the closure of the ACCT and the post-closure review. Certainly, no mention is
made in the record of the review. Given that observations in the ongoing
record would have ceased on 28 April, the wing history sheet seems a
sensible document to consult in order to check for any concerns raised in the
intervening period.
162. In this particular case, the officer had made an entry in the man’s wing history
sheet on 3 May, stating that he had had an unsettled week and had not gone
to work on two occasions. The entry did not provide any further context or
clarification, and whilst the SO may have spoken to the officer or considered
the document in the review, there is no evidence that this was the case. The
issues here are twofold. When an ACCT is closed, observations are quite
properly no longer documented in the ongoing record, and so it is essential
that any concerns are fully documented elsewhere, particularly in the period
between the closure of the document and the post-closure review. It is
equally important that, where such concerns are recorded, they are
considered as part of the post-closure review process, and the result of these
considerations is recorded on the review document.
163. It is easy to attach retrospective significance to the officer’s entry in the man’s
wing history sheet, whereas it is quite possible that at the time, there was no
reason for immediate concern. However, this demonstrates further the need
for such entries to be comprehensive and unambiguous, particularly in the
period between the closure of the ACCT and the post-closure review meeting.
The Governor should remind staff that documents such as wing history
sheets should accurately and clearly record any concerns, particularly
in the period between ACCT closure and post-closure review.
In addition, the Governor should ensure that staff attending an ACCT
post closure review consider all the evidence, including the wing history
sheets, about the prisoner’s wellbeing since the ACCT procedures were
closed.
Single cell accommodation
164. On 23 February, after the man had been released from and subsequently
recalled to Portland, he self-harmed by burning his arm with a cigarette
lighter. This was the second occasion on which he had harmed himself in this
way. The following day, an Immediate Action Plan was completed by two
officers and the nurse. They indicated that, in terms of cell sharing, the man
Final Report: 38
Date: September 2010
was a high risk due to the nature of his self-injury. Ostensibly, the man could
have caused harm to a person sharing his cell because his method of self-
harm involved the potential for fire.
165. When the man arrived at Glen Parva on 31 March, the CSRA concluded that
he was a medium risk. No mention was made of the way in which he had
harmed himself at Portland some five weeks earlier, and there is no reason to
believe that this information was available to the reception officer completing
the assessment. That said, the man was, at the time of his arrival at Glen
Parva, subject to the ACCT document opened on 23 February at Portland
after he burned his arm. Even a cursory look at the document would have
revealed the reasons why it was opened, and this may have had some
bearing on the decision regarding cell sharing.
Reception officers completing the CSRA for ACCT prisoners should
check the document for concerns about cell sharing
166. As a result of being assessed as a medium risk on the CSRA, the man was
not prohibited from sharing a cell. Indeed, he was located in a shared cell
both on the induction unit and on Unit 1. This did not appear to create any
problems at first. The man got on well with his cellmate, when located on the
induction unit, and they continued to share a cell when they moved to Unit 1
at the same time. The cellmate told my investigator that he had a good
relationship with the man and considered him a friend. He said, however, that
the man was often drowsy and slept a lot due to his medication, and so did
not always provide the best company. As a result, the cellmate eventually
asked to be moved to another cell, though he remained friends with the man.
Another prisoner moved into the man’s cell.
167. On 27 May, a cell sharing risk review was instigated after the nurse
approached the SO. The nurse had spoken to the man, who had told him that
sharing a cell was affecting his state of mind. The review acknowledged this
and also mentioned the possibility of injury to the man’s cellmate as a result of
the man’s mental health problems. Single cell accommodation was identified
as a specific need.
168. Five days after being granted single cell accommodation, the man was found
hanged in his cell. His mother has expressed concern that he was in a single
cell and feels strongly that, given his mental health issues and risk of suicide,
he should have been sharing with another prisoner.
169. At the time of the cell sharing risk review, the man was no longer subject to
the ACCT process. Members of staff involved in the administration of that
document, including mental health professionals, felt that the man’s risk of
self-harm or suicide had diminished to such a degree that the additional
monitoring and support was unnecessary. When he was given access to a
single cell, he was not thought to be at risk of harming himself.
170. Even if the man had been considered at risk of self-harm or suicide, this
would not by itself have been sufficient reason to locate him in a shared cell.
Final Report: 39
Date: September 2010
Prison Service Order (PSO) 2700 is clear that, when managing a prisoner
likely to self-harm or attempt suicide, it is not an appropriate risk management
strategy to place the person in a shared cell and expect their cellmate to
shoulder the burden of responsibility for monitoring and support. Whilst cell
sharing can help to reduce feelings of loneliness and provide the prisoner with
someone to talk to, this must not be used as an alternative to staff-prisoner
interaction.
171. In the man’s case, the decision to move him to a single cell was made
because of his mental health symptoms rather than in spite of them. The cell
sharing risk review was prompted by a nurse, a mental health professional,
who had spoken to the man about his concerns. Members of staff must, of
course, be aware of the possibility that such requests might be made in order
for a prisoner to more easily implement a plan that they have formulated for
self-harm or suicide. However, in this case the man was not considered to be
at imminent risk, the review was multi-disciplinary in nature, and the decision
was taken with the intention of alleviating concerns arising from his mental
health issues. I am, therefore, satisfied that the SO and nurse acted not only
in good faith but also reasonably, with regard to the review process and the
decision reached.
Prison transfers
172. The man spent the majority of his prison sentence in Portland, though he also
spent time in High Down, Feltham, Dorchester, and of course Glen Parva. A
summary of these transfers is set out below.
DATE STATUS
7 April 2008 Received into High Down on remand
12 June 2008 Transferred to Feltham after conviction
24 July 2008 Transferred to Portland one week after sentencing
6 January 2009 Released on licence from Portland
21 January 2009 Received into Dorchester after licence recall
28 January 2009 Transferred to Portland
24 March 2009 Transferred to Feltham
31 March 2009 Transferred to Glen Parva
173. It is not uncommon for prisoners to be remanded in one prison and
transferred to another after conviction. After being sentenced in July 2008,
the man transferred to Portland and remained there for more than five months
until he was released in January 2009. After being recalled to custody, just a
fortnight after his release, the man spent a week at Dorchester before being
transferred to Portland, where he remained for almost two months.
174. The main area of concern relates to the man’s transfer from Portland to
Feltham on 24 March, and then to Glen Parva seven days later. At the time of
Final Report: 40
Date: September 2010
these transfers, the man was subject to the ACCT process. During interview,
the SO, who chaired a number of the man’s ACCT reviews at Glen Parva,
mentioned that it was unusual for prisoners subject to open ACCT documents
to be transferred between prisons. Certainly, this practice is not encouraged
unless there are specific and valid reasons relating to the continued care of
the prisoner at risk.
175. Regarding the man’s transfer from Portland to Feltham, there does not appear
to be a great deal of clarity about the reasons behind the move. He was told
on more than one occasion that the purpose of transferring him to Feltham
was to facilitate better support through location in the healthcare unit.
However, the nurse wrote in the clinical record on 17 March that whilst there
was a possibility of the man transferring to Feltham, this would “not be under
a clinical move”.
176. Chapter 15, paragraph 15.7.3 of PSO 2700 states that “the proposed transfer,
and issues arising from it, must be discussed at a case review with the
prisoner”. Paragraph 15.7.4 goes on to say that “the prisoner should be given
information about the regime and facilities of the new environment”. Whilst
the transfer to Feltham was discussed with the man at ACCT reviews, the
focus seemed to be on the more comprehensive provision of healthcare, with
a strong implication that he would be managed as an in-patient at Feltham’s
healthcare unit. However, there is no evidence to suggest that the man had
been assessed for suitability prior to his transfer.
177. In terms of information sharing in advance of transfers, chapter 15, paragraph
15.7.2 of PSO 2700 states:
“The intention to transfer a prisoner on an open ACCT Plan … must be
discussed with the receiving establishment, a record must be retained in
the sending establishment to show this has been done (as well a record
[sic] made in the ACCT Plan), and relevant information must be conveyed
either with or ahead of the prisoner.”
178. My investigator asked a Safer Custody officer at Portland, to ascertain
whether or not any such discussion took place. The Safer Custody officer
explained that, when transferring a prisoner subject to ACCT, his office would
usually fax the documents to the receiving prison in advance of the transfer,
and keep a copy in the Safer Custody department. Although the officer had
recorded on a spreadsheet that he had faxed the man’s paperwork to Feltham
on 23 March, the day before his transfer, he was not able to locate the
documents themselves. There is no mention in the man’s ACCT document of
a discussion about the proposed transfer, particularly with regard to
assessment for healthcare admission. This raises the possibility that staff at
Portland made a decision to transfer the man to Feltham in the hope that he
would meet the criteria for the healthcare unit.
179. Feltham’s Safer Custody office explained to my investigator that the prison’s
protocol for transferring prisoners subject to ACCT involves identifying a
specific person in the receiving prison and sending the documents to them in
Final Report: 41
Date: September 2010
advance of the transfer. In this case, the allocations officer at Feltham faxed
the man’s ACCT documents to the SO at Glen Parva on 30 March. There is
no indication, though, that any meaningful discussion took place between the
two prisons about the way in which the man would be managed.
180. On the subject of the transfer from Feltham to Glen Parva, the reasons for the
move are not at all clear. The man’s ACCT Caremap was updated on 30
March. The entry related to reducing anxiety, and suggested that he should
move to Glen Parva at the earliest opportunity because he wanted to live in
Leicester upon release. However, this was clearly being considered as early
as 25 March, only one day after the man’s arrival at Feltham, when an officer
wrote in his ongoing record:
“Mood is clearly low, and I fear that it is unlikely to improve for some time,
as any news we are in a position to tell him will not be what he expects to
hear. I believe the plan is for him to go to Glen Parva, which will be bad
news for him if true.”
181. The day after this entry was made, the man was told during an ACCT review
that he would be transferred to Glen Parva. The full wording of the review
document is as follows:
“The man has been informed that he will not be going to Lapwing, and he
will be going to Glen Parva at the earliest opportunity. The man accepted
what he was told and will be seen again tomorrow.”
182. It is clear from the ACCT documentation that the man was keen to be
accepted in the healthcare unit, and that news to the contrary would be
unwelcome and upsetting. It is, of course, impossible to glean in full the
overall tone of an ACCT review by consulting the paperwork, but the wording
of the form gives the impression that the review was little more than an
exercise in conveying information. The form states that the man “accepted
what he was told”, but does not give any indication as to his general
demeanour, his response to the news, or any concerns regarding the transfer.
183. On 31 March, the man transferred from Feltham to Glen Parva. As mentioned
above, the reason for the move was that he wished to live in the Leicester
area upon release. However, he was not due to be released from custody
until October 2009, and so I am sceptical about the benefits that another
unsettling transfer could offer, particularly only a week after arriving at
Feltham.
184. I am concerned about the apparent lack of meaningful communication
between the prisons regarding the transfer of a prisoner subject to an open
ACCT document. I am also unconvinced about the benefit of the transfers
themselves. Even if relocation to Glen Parva was considered a positive move
for the man, involving Feltham in the process seems only to complicate the
issue. Between 24 and 31 March, a period of only a week, the man was
transferred twice. By 7 April, he had moved from Glen Parva’s induction unit
Final Report: 42
Date: September 2010
to a normal residential location. Such a succession of transfers was far from
ideal for someone considered to be at an elevated risk of self-harm or suicide.
Clinical care
185. The clinical reviewer, from Leicestershire Partnership Trust, completed a
clinical review, which is annexed to this report. The purpose of the clinical
review was to consider the circumstances of the man’s time in custody and
his death from a medical perspective and to consider whether the clinical care
received was equitable to that which would have been received in the wider
community.
186. The clinical reviewer thinks that the man’s death was not preventable. He
noted that the man suffered from depression over a prolonged period, and
thought it would have been very difficult to predict that his low mood in the
days before his death might lead to a suicide attempt. The clinical reviewer
also judges that the man’s medication was appropriate. He believed the
man’s clinical care was equivalent to what he would have received in the
community.
187. The man had regular mental health support throughout his time in custody.
Although he was not on the MHIT caseload for much of his time at Portland,
the primary healthcare team was extensively involved. At some points, RMN
was seeing the man twice daily. When he arrived at Glen Parva, the man was
seen by a psychiatrist and this was followed up with two further appointments.
He was accepted on to the MHIT caseload and was seen by a nurse on a
number of occasions.
188. The man was prescribed a number of different anti-depressants whilst he was
in custody, but they did not seem to improve his mood for significant periods.
Regardless of the type of medication he was taking, the man seemed to
experience fluctuations in mood and, at certain points, was very low indeed.
189. Regarding the healthcare staffing at Glen Parva, the clinical reviewer
acknowledged that the separate teams were to be consolidated, providing a
streamlined service. Progress had also been made in terms of the staffing
levels for the healthcare centre.
190. The structure of the MHIT at Glen Parva was such that, if the nurse was away
from the prison for any reason, there was nobody to cover her appointments.
Although they could be covered by the primary mental health team, there was
no specific diary system to allow such contingency measures to be easily
enacted. Responding to the draft report, Leicestershire Partnership Trust
noted that at the time, there was a vacancy for a further permanent staff
member to assist the nurse with appointments for those on the MHIT
caseload, and that an additional nurse did attend the prison and could cover
the nurses appointments when necessary.
191. The clinical reviewer noted that people subject to the ACCT process (a
discipline-led rather than clinically led procedure) had regular reviews which
Final Report: 43
Date: September 2010
took place as planned, but the system was less robust for those only on the
MHIT caseload. He made the following recommendation, which I endorse:
The healthcare manager should examine the internal system for setting
review schedules for those not being monitored under ACCT, to ensure
that it is watertight.
192. The clinical reviewer concluded that failing to take anti-depressant medication
for just a few days would probably not have had serious effects, as it usually
takes more time for the effects to be felt after withdrawing from this type of
treatment. However, he thought the follow-up arrangements should be
reviewed, and I endorse his following recommendation:
The healthcare manager should review the arrangements for following
up prisoners who do not collect their medication. This is particularly
important for prisoners who are vulnerable due to mental health
symptoms.
Events of 2 June 2009
193. The man’s mother feels strongly that her son should have been checked more
frequently during the night. However, he was neither subject to the ACCT
process nor on a list of prisoners giving cause for concern. Therefore, he
would not have been checked specifically at regular or recorded intervals. As
mentioned earlier, OSGs patrol the units half-hourly during the night, looking
into cells at random. It is important that a balance is struck between
monitoring prisoners and affording them privacy during the night, which is why
only those prisoners thought to be at risk are subject to regular, frequent and
recorded checks.
194. After the alarm was raised by an OSG at around 4.30am, the response was
swift. Several officers arrived on the scene within a few minutes. The gate
log indicates that an ambulance was called at 4.35am and arrived at the
prison at 4.40am. The nurse began CPR as soon as she arrived on Unit 1
just a couple of minutes after the OSG raised the alarm, though the use of the
defibrillator was delayed by a few minutes as the officer had to retrieve it from
the healthcare unit. I am satisfied that this delay would not have made a
difference in this case; the nurse’s description suggests that the man may
have been dead for some time before being discovered. However, the
importance of a defibrillator being available quickly cannot be underestimated,
and in many cases a delay of only a few minutes can be significant in
affecting the chances of effective resuscitation.
Healthcare staff should take an emergency ‘grab bag’ and a defibrillator
to serious situations, particularly those of a ‘code blue’ nature.
The Governor and healthcare manager should consider placing
emergency ‘grab bags’ and defibrillators at strategic points throughout
the establishment.
Final Report: 44
Date: September 2010
195. After the man’s death was confirmed by paramedics at the scene, the
contingency plan for a death in custody was implemented. There are
separate, slightly different plans depending upon whether the death occurs at
night or during the daytime. In this case, the daytime plan was used because
the daytime regime would soon begin. A log was kept, initially of people
attending Unit 1, then of people attending the specific landing, and later of
those attending the cell itself. Various agencies were contacted regarding the
man’s death. The Chair of Glen Parva’s Independent Monitoring Board (IMB),
mentioned that his duty member of staff was not contacted until 7.45am, more
than three hours after the man was found. The contingency plan does not
specifically mention the need to contact the IMB, which may explain the delay
in initial contact following the man’s death. My investigator discussed this
issue with a Governor, who explained that the contingency plans were in the
process of being re-written and that this issue would be noted.
The updated contingency plan for actions following deaths in custody
should include a requirement to contact the IMB.
Allegations made after the man’s death
196. Following the man’s death, a number of allegations were made about his
treatment whilst at Glen Parva. Several prisoners made statements and an
anonymous letter from the parent of a serving Glen Parva prisoner was sent
to the Chief Inspector of Prisons.
197. The allegations were that:
(cid:127) The man had been bullied by three prisoners who worked on the Unit 1
servery.
(cid:127) The man been ridiculed by members of the Unit 1 staff.
(cid:127) The man had an obvious and fresh ligature mark on his neck on the
weekend before his death.
(cid:127) Prisoners on Unit 1 had, upon realising that something was wrong, tried
in vain to get the attention of the OSG on the night of 1-2 June.
Bullying by other prisoners
198. Following the allegations, the Governor asked a PO to conduct a simple
enquiry. This involved interviewing the prisoners who had made the claims,
as well as those accused of bullying the man. Although the PO did not come
to a conclusion about whether the man had been bullied, he acknowledged
that altercations had taken place with the three accused prisoners. These
prisoners returned to normal location but were prevented from being
employed as servery orderlies.
199. As part of the Ombudsman’s investigation process, the investigator
interviewed four prisoners who lived on Unit 1 when the man died. Three of
the prisoners had made statements to unit staff, and the fourth person came
to light as someone who had known the man well. Two prisoners who had
made statements had either been transferred or released and, whilst it was
not feasible to interview them, their statements were considered.
Final Report: 45
Date: September 2010
200. A prisoner said in interview that he had not known the man particularly well
but had shared a cell with one of the prisoners who had worked on the
servery. The prisoner said this prisoner talked about the way in which the
man was treated differently and given smaller portions of food. The prisoner
also said he witnessed the servery orderlies making fun of the man, forcing
him to sing nursery rhymes to try and humiliate him. In addition, he recalled
an incident when the servery orderlies banged on the man’s cell door.
201. Another prisoner gave much the same account, though he had not personally
witnessed anything and instead had been told by others that the man was
being bullied. The statements made by two prisoners have also made
reference to the servery orderlies kicking the man’s cell door and shouting
abuse at him.
202. Conversely, two other prisoners’ were not convinced that the man had been
bullied. One of the prisoners said in interview that whilst there had been
some verbal exchanges between the man and the servery orderlies, these
were of a good-humoured nature and much the same as any other such
interaction between prisoners. He said that there had been one more serious
problem, which led to the aforementioned incident involving someone banging
on the man’s door, but that this was resolved quickly. A prisoner said in
interview that the allegations about bullying were entirely false, and had been
invented by a prisoner on the unit after the man’s death. He said he was
close to the man and would have expected him to say if he had been bullied
by other prisoners.
203. The PO mentioned during interview that the three servery orderlies accused
of bullying the man were temporarily segregated whilst they were interviewed.
The prisoners admitted that there had been altercations with the man about
food, and that they had also approached the man about his personal hygiene.
However, the PO did not feel that there had been a sustained campaign
against the man. The servery orderlies were returned to normal location,
though not to Unit 1 because of the possibility of reprisals from other
prisoners.
204. It is impossible to be certain about exactly what happened between the man
and the servery orderlies, how he might have felt about the altercations that
took place, and whether their interactions were malicious or in jest. Prior to
the man’s death, there were no reports of bullying or intimidation, and there is
nothing of that nature recorded in his wing history file or the unit observation
book. It is easy to imagine the way in which a rumour can circulate amongst
prisoners on a unit, and indeed some of the information obtained during
interview was second hand rather than directly witnessed.
205. I do not make a recommendation in this area. However I advise the Governor
and Safer Custody manager to remind unit staff that seemingly minor
altercations might be more powerful when directed at someone who is
vulnerable or withdrawn from the regime.
Final Report: 46
Date: September 2010
Ridicule from members of Unit 1 staff
206. The letter sent to the Inspector of Prison’s Office by the parent of a Glen
Parva prisoner mentioned that unit staff made derogatory comments to Levi
about his personal hygiene. Two more prisoner’s also mentioned this in their
statements, though one of them had not witnessed anything directly and said
he had heard about the issue from another prisoner. The prisoner did not
refer to this in the statement he made shortly after the man’s death, though in
interview on 14 October, some four months later, he said that an officer had
given the man “a hard time” in relation to his personal hygiene. A prisoner,
however, said there had been no problems between the man and the unit staff
and, similar to the allegation of bullying, felt that the man would have told him
about any problems.
207. The investigator interviewed a number of Unit 1 officers and asked them
about the allegations. Some officers were aware of issues around the man’s
personal hygiene, but robustly denied that he had been subject to any ridicule.
During interview, the officer said prisoners who did not shower or clean their
cells were encouraged to do so, but would never be ridiculed or mistreated
because this would not only be wrong but also self-defeating.
208. There are similarities here to the allegations around bullying, as it is
impossible to know exactly what unit staff members might have said to the
man, and in what context. As with the bullying issue, some of the accounts
are second hand. During interview, no members of Unit 1 staff recalled
witnessing or engaging in behaviour involving ridicule or derogatory remarks
towards prisoners in their care. In fact, several staff members seemed
genuinely surprised and affronted to be faced with such allegations.
209. Although not related to seriously inappropriate behaviour towards prisoners,
my investigator heard several officers routinely referring to prisoners by their
surnames. This was also highlighted as an issue in the 2007 HMCIP report,
which recommended in paragraph 2.59 that “staff should address prisoners by
their preferred names”. Whilst I do not make a recommendation about this
issue, I bring to the Governor’s attention the need to remind staff that
prisoners should be addressed by their given names.
Ligature mark
210. Two prisoners both wrote about having witnessed a ligature mark on the
man’s neck, on the weekend before his death. Another prisoner also
mentioned this, though it was not something he had witnessed directly. A
prisoner said in his statement that he had spoken to the man about it, and
believed that he had tried to hang himself on the Saturday night.
211. The prisoner said in interview that he had spoken to the man about the mark
on his neck, and understood that it was the result of a hanging attempt.
Another prisoner also said he had noticed the mark and had tried without
success to talk to the man about it. He nevertheless felt that the cause of the
Final Report: 47
Date: September 2010
mark was very obvious. A prisoner gave a detailed and credible account of
seeing a ligature mark on the man’s neck, and taking him aside to talk to him
about it. He said this was on the Saturday afternoon before the man’s death
overnight on the following Monday/Tuesday.
212. None of the prisoners said that they reported what they had seen to unit staff.
A prisoner thought some members of staff had noticed the mark and arranged
for the man to be seen by someone from the healthcare unit. However, there
does not appear to be a record of any such action. The Unit 1 officers
interviewed did not remember a mark on the man’s neck and were clear that
action would have been taken had one been noticed. The prisoner mentioned
three officers as the people who might have reported the mark to the
healthcare unit. Two of the officers were not working on the weekend before
the man’s death, and there is no officer under the third name. However, this
could refer to the officer with a similar name, who was working on Unit 1 on
the weekend before the man’s death.
213. In interview, the officer was very clear that he had not noticed a ligature mark
around the man’s neck. He said that if he had noticed anything of this nature
he would “have had him out of that cell straight away … got in touch with
healthcare [and] had him on an ACCT”. He went on to say that such
immediate action would be common sense, and that a ligature mark would be
an indicator of serious risk. The officer was also of the opinion that all of his
colleagues would treat such an observation very seriously.
214. There is nothing documented in either the man’s discipline file or clinical
record to suggest that a mark on his neck was noticed by members of staff. A
number of prisoners report seeing this mark, and their statements cannot be
discounted. However, the concerns were not brought to the attention of
officers on the unit. It does not seem that members of unit staff saw a mark
on the man’s neck and failed to act; rather, they were unaware of any such
mark.
Allegations about staff response on the night of the man’s death
215. The anonymous letter sent to the Chief Inspector’s office made the following
claim:
“On the night he committed suicide the lads next door realised that
something was wrong and did all they could to get attention and help.
Nobody responded until the morning when of course it was too late.”
216. The cells on Unit 1 have clear observation panels in the doors, rather than
privacy flaps. For this reason, it is possible to look from one cell into the cell
directly opposite. A prisoner said in interview that he thought another
prisoner, who was opposite the man, had seen him hanging in his cell and
tried without success to raise the alarm by using his cell alarm. The prisoner
however said that he heard a cell alarm bell earlier in the night but was not
sure whose cell it came from. He later heard officers on the landing outside
the man’s cell, and the nature of the conversations made it clear that
Final Report: 48
Date: September 2010
something was wrong. It was at this point that he looked through the
observation glass and saw officers cutting the man down. He said he heard
later that the man had pressed his cell alarm to try to summon help but none
had arrived.
217. Another prisoner said, in interview, that he was woken at around 4.30am by
the commotion on the landing. He said that a board on the landing was
illuminated, indicating that a cell alarm had been activated. The prisoner
could see the light from the board, but was not able to see which cell it related
to. He said that when cell alarms are deactivated by members of staff, the
light on the board goes out. For this reason, he assumed that Levi had
attempted to alert a member of staff to his situation but had not elicited a
response.
218. My investigator asked an OSG if, prior to discovering the man at around
4.30am, there had been any cell alarms or noise from prisoners. He said
there had not, and that it had been a quiet night on Unit 1 until that point. The
electronic records show that the OSG patrolled the landings at roughly half-
hourly intervals. It therefore seems unlikely that he would walk directly past a
cell where the alarm had been activated, and do nothing to address the issue.
219. When a cell alarm is pressed on Unit 1, a red marker drops down at the end
of the landing in question. An electronic panel also located at the end of the
landing, also lights up to indicate which cell has activated the alarm. In the
unit office, a red light indicates which of the three landings has activated a cell
alarm, but does not give details of the specific cell. The lights are
extinguished when the alarms are deactivated. The system does not make a
permanent electronic record of cell alarms. Between the hours of 9.00pm and
7.00am, if cell alarms are not answered after three minutes, an electronic
notification is sent to the gate. The gate officer is then able to alert the unit
officer to the unanswered alarm.
220. The information provided by prisoners on this matter is largely speculation
and assumption based on the piecing together of partial facts. The letter is
third party information based on the same speculation. The OSG gave a
credible account of the sequence of events, and the content of his interview
was consistent with that of other officers. He patrolled the landings half-hourly
as required, and did not recall any prisoner unrest or cell alarms. There is no
reason to believe that the events of 1 to 2 June unfolded in any way other
than as described by the OSG and other members of staff.
Issues raised by the man’s family
221. The man’s brother and mother raised a number of issues with my investigator
and family liaison officer (FLO). The issues concerning ACCT monitoring,
single cell accommodation, checks during the night, resuscitation attempts,
and the ligature have been covered earlier in the report. The remaining
issues concern serious assaults against the man, his location in the prison,
and family liaison following his death.
Final Report: 49
Date: September 2010
Assaults against the man
222. The man’s mother said she had heard that a prisoner was stabbed after being
mistaken for the man. She also thought the man had been seriously
assaulted during or after a game of pool. The man’s mother was concerned
about these issues, which she described as attempts on his life, and said they
may have been racially motivated. She did not know when or in which prison
the incidents occurred.
223. In order to investigate the man’s mother’s claims, my investigator contacted
the security department at High Down, the governing Governor at Portland,
the senior officer from the security department at Dorchester, and the senior
officer from the security department at Feltham. There was no evidence of a
prisoner being stabbed at any of the four prisons during the time that the man
was there. Portland had a record of the previously mentioned assault against
the man in February 2009, when he was assaulted by other prisoners on the
Drake unit, but there were no other reports that he had been assaulted. The
assault in February 2009, and that mentioned by the man’s mother, may be
the same incident, though it is impossible to be certain about this matter.
Other information related to concerns around self-harm that have already
been documented in the Key Findings section of this report.
224. The man transferred to Glen Parva on 31 March 2009 and remained there
until his death on 2 June. There were no reports of him being assaulted
during this period. My investigator asked a governor if there had been any
incidents involving a prisoner being stabbed, and was told that there had not.
225. There is no evidence that a prisoner was stabbed after being mistaken for the
man. Other than the assault in February 2009, it appears that he was not
involved in any violent incidents.
The man’s location in the prison
226. The man’s mother felt that he should have been located in the healthcare unit
because of his bipolar disorder, and wondered why he was instead located on
an ordinary residential unit.
227. The man appeared to classify himself as suffering from bipolar disorder, and
indeed this was also mentioned on occasion by members of medical staff.
However, bipolar disorder is a specific mental illness and there is no evidence
that this was ever officially diagnosed. Certainly, though, he suffered from
depression, and at times there were serious concerns about his well-being
and his risk of self-harm or suicide.
228. During the man’s first spell at Portland, he spent much of his time on the
Beaufort unit, a skills development area where activities such as a music
room were available. Following his recall to custody, the man was located on
a normal residential unit. However, concerns were raised on a number of
occasions, particularly by his personal officer, that his needs could not be
appropriately managed in such an environment. A number of references are
Final Report: 50
Date: September 2010
made in the man’s documents regarding his proposed transfer to Feltham
which suggest that the intention was for him to be located on the healthcare
unit. However, this does not appear to have been agreed in advance of his
transfer.
229. Upon arrival at Feltham, the man was assessed by the CMHT but was not
considered suitable for admission to the healthcare unit. Shortly afterwards,
he was transferred to Glen Parva, where he remained on normal residential
location until his death. Whilst he was subject to an open ACCT document
throughout this period, the man seemed to settle on a residential unit and his
review documents indicate progress.
230. Whilst the man suffered from depression and subject to ACCT, this by itself
would not indicate a need for location on the healthcare unit. It is entirely
possible to look after prisoners with mental health needs on normal residential
location, and in some cases location on the healthcare unit can itself be a
source of stigma. Although he was on a normal residential unit, Levi had
regular support from the MHIT.
Family liaison
231. The man’s mother said she initially found the family liaison from Glen Parva
supportive and helpful. However, following a family dispute about where the
man should be laid to rest, she felt that one of the prison’s family liaison
officers inappropriately took her son’s side. She was also concerned about a
voicemail message she received from the officer, which appeared to relate to
another prisoner entirely.
232. My investigator spoke to the prison liaison officer about these matters. He
admitted that the family liaison with the man’s mother had become difficult,
though he did not agree with her assessment of why this was. The officer
said that, when the family dispute arose, he felt that the man’s mother tried to
convince him that he should side with her. He told my investigator that it
would not have been appropriate for him to become involved in what was
essentially a family matter. The officer added that the man’s mother found it
difficult to accept that the prison was not able to cover certain expenses, in
particular a wake following the funeral. He was quite clear that he did not
believe he had taken sides in the family dispute, and said he had acted
independently and professionally.
233. On the issue of the voicemail message, the man’s mother said it was from the
officer and related to a prisoner who was very much alive. She said that in
the message, he referred to speaking to a prisoner about an issue. She said
she was very upset to receive such a message so shortly after the man’s
death, and her instant reaction was to delete it. When my investigator asked
the officer about this, he denied leaving such a message on the man’s
mother’s voicemail service. He also denied the possibility that it could have
been left in error, despite him working in the visits centre at the time and
having responsibility for contacting families on a regular basis.
Final Report: 51
Date: September 2010
234. Given that there is no evidence of the message, it is impossible to reach a
conclusion about what might have happened. With two opposing accounts,
and no corroborating evidence, it is not possible to be sure about the facts of
this matter. Nevertheless, the Governor will wish to remind family liaison
officers of the importance of respecting family sensitivities. Consideration
should be given to writing to the man’s mother to apologise for any distress
caused.
Final Report: 52
Date: September 2010
CONCLUSIONS
235. The man was sentenced to 18 months’ imprisonment on 17 July 2008. It was
his first conviction and prison sentence. The man had suffered from
depression since his teenage years and was haunted by the memories of
traumatic incidents that he had witnessed.
236. The man spent almost all of the first part of his sentence at Portland. He
suffered from depression and fluctuations in mood, and harmed himself on a
number of occasions. He was subject to the ACCT process and had regular
support from mental health workers. The man was prescribed anti-
depressants but they did not seem to have a sustained positive effect on his
mood.
237. Although he was released on 6 January 2009, he was recalled to custody only
two weeks later. After a very short period at Dorchester, the man transferred
back to Portland. He continued to suffer from depression, and his medication
and ongoing support did not seem to alleviate this very much.
238. The man transferred to Feltham on 24 March, and to Glen Parva on 31
March. He saw a psychiatrist on several occasions, and received support
from Glen Parva’s mental health team.
239. On 27 May, he requested a single cell, and this was granted. In the early
hours of 2 June, he was found hanging in his cell by the night patrol officer.
Other officer and a nurse attended quickly. Resuscitation was attempted but
this was unsuccessful.
240. My report covers the sad story of a young man who did not seem able to find
any relief from his ongoing depression. I have paid particular attention to the
ACCT process, single cell accommodation, and transfers within the prison
system. I also looked into several allegations that were made after the man’s
death. I make eight recommendations and endorse a further two made by the
clinical reviewer.
Final Report: 53
Date: September 2010
RECOMMENDATIONS
1. The Safer Custody manager should remind staff that ACCT reviews should
take place according to the prisoner’s circumstances rather than at standard
intervals.
The recommendation was accepted. Senior officers will be briefed at their
morning meeting about the timing of reviews. A follow-up notice to staff will
be issued, reminding staff that ACCT reviews are determined by a prisoner’s
need and risk rather than at set intervals.
2. The Governor should remind all staff to complete the ACCT document
properly, with high quality, meaningful entries.
The recommendation was accepted. A notice to staff has been issued,
outlining the expectations of entries in ACCT documents. This will be
monitored by management checks.
3. The Governor should remind staff that documents such as wing history sheets
should accurately and clearly record any concerns, particularly in the period
between ACCT closure and post-closure review.
The recommendation was accepted. Senior officers will be briefed at their
morning meeting about the expectation of P-NOMIS entries, particularly for
prisoners in the period between the closure of their ACCT and their post-
closure review. Senior officers will relay the information to their members of
staff, and compliance will be checked by managers.
4. In addition, the Governor should ensure that staff attending an ACCT post
closure review consider all the evidence, including the wing history sheets,
about the prisoner’s wellbeing since the ACCT procedures were closed.
The recommendation was accepted. Senior officers will be briefed at their
morning meeting about the need to include all relevant sources of information
about a prisoner for post-closure reviews. A follow-up notice to staff will be
issued, and compliance will be checked by managers.
5. Reception officers completing the CSRA for ACCT prisoners should check the
document for concerns about cell sharing.
The recommendation was accepted. First night officers will be briefed about
the importance of checking ACCT documents for concerns about cell sharing
when completing CSRAs. A follow-up email will be sent to all first night
officers, and compliance will be checked by managers.
6. The healthcare manager should examine its internal system for setting review
schedules for those not being monitored under ACCT, to ensure that it is
watertight.
Final Report: 54
Date: September 2010
The recommendation was accepted. The healthcare arrangements now
include three handover periods per day to ensure that reviews are not missed
or can be re-allocated if necessary. This is supported by a diary system and
alerts on the clinical computer system.
7. The healthcare manager should review the arrangements for following up
prisoners who do not collect their medication. This is particularly important for
prisoners who are vulnerable due to mental health symptoms.
The recommendation was accepted. All prisoners are now routinely followed
up if they do not collect their medication. Prisoners are required to sign a
disclaimer if they do not wish to have their medication, and discussions will
take place about the reasons for this.
8. Healthcare staff should take an emergency ‘grab bag’ and a defibrillator to
serious situations, particularly those of a ‘code blue’ nature.
The recommendation was accepted. An emergency ‘grab bag’ is in place,
and specific bags for ‘code blue’ and ‘code red’ situations are being put
together. Defibrillators are now located alongside the bags for ease of
access.
9. The Governor and healthcare manager should consider placing emergency
‘grab bags’ and defibrillators at strategic points throughout the establishment.
The recommendation was partially accepted. It was acknowledged that this
would be beneficial, but it will not be implemented at this time due to issues of
ownership, cost, responsibility, litigation and accountability. The healthcare
centre will continue to hold emergency equipment.
10. The updated contingency plan for actions following deaths in custody should
include a requirement to contact the IMB.
The recommendation was accepted. The contingency plan was reviewed and
now includes a requirement to inform the IMB of deaths in custody.
Final Report: 55
Date: September 2010