Individual at Dartmoor

Investigation into the circumstances surrounding
the death of a man at
HMP Dartmoor in January 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2010
The man was 38 years old when he died in January 2009, in his cell at HMP
Dartmoor. He was found hanging. He had been treated at HMP Exeter for
schizophrenia until a week beforehand. The investigator and Family Liaison Officer
join me in offering our sincere condolences to his family and friends for their sad
loss.
I wish to thank the Governor of Dartmoor and the Deputy Governor for making the
necessary facilities and information available to the investigator. I also thank the
prison Liaison Officer for his assistance.
In the course of the investigation, I asked for a clinical review to be carried out into
the medical care and treatment the man received in custody. A clinical reviewer was
appointed by the local Primary Care Trust to undertake a clinical review on my
behalf. He was assisted by a Consultant Psychiatrist. I am extremely grateful for
their assistance and report.
For the purpose of this report, I have concentrated on the time from when the man
first arrived at Dartmoor in July 2008. In October he cut his wrist and from then on
he was monitored under the suicide and self harm procedures, until his death three
months later. I make 11 recommendations including a commendation for an officer
who placed his own health at risk whilst attempting to resuscitate him.
I must apologise to the Coroner and the man’s family for the delay in producing this
report.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Deputy Ombudsman March 2010
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CONTENTS
Summary
The investigation process
HMP Dartmoor
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man had a long history of mental health problems, for which he had received
treatment and hospitalisation whilst in the community. When he arrived at prison, his
medical history was noted and a number of support mechanisms put into place.
After arriving at Dartmoor in July 2008, it was noted by healthcare staff that the man
had been diagnosed with paranoid schizophrenia. He was prescribed a number of
different medications to help his symptoms.
In October, the man cut his wrist and from then on, suicide and self harm monitoring
began. (The procedure for monitoring is known as Assessment, Care in Custody
and Teamwork (ACCT) which I explain in greater detail later in the report.) As well,
due to concerns about his mental health, he was transferred to Exeter as an in
patient in the prison hospital. His condition became worse and then improved. He
continued to receive support from mental health in-reach staff and a psychiatrist. (In-
reach forms part of the community mental health team and offers support to
prisoners.) In January 2009, he was deemed well enough to return to Dartmoor and
when he arrived there, he was allocated to A wing.
Six days later, in January, the man’s behaviour became a cause for concern and in
order to keep him safe, Exeter healthcare were asked whether they were able to
take him back. Unfortunately, there were no beds available and he remained at
Dartmoor.
That evening, an ACCT case review took place and consideration was given as to
whether the man should move to a safe cell. He was unhappy about moving and so
staff considered whether force should be used. However, the manager considering
the option was unable to find any guidance. Instead, he remained in his cell and was
monitored every hour. Shortly after midnight, whilst carrying out a routine check, he
was found hanging in his cell.
I make ten recommendations aimed at improving systems at Dartmoor and one
which commends an officer. Five recommendations refer to Dartmoor’s suicide and
self harm procedures, five are intended to improve healthcare arrangements and one
recognises the efforts made to resuscitate the man.
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THE INVESTIGATION PROCESS
1. When the Ombudsman’s office was notified in January 2009 of the man’s
death, the investigation was allocated to a Senior Investigator. He
contacted the Governor and arranged to travel to the prison to meet him
and his team for the purpose of opening the investigation.
2. In February, the investigator met the Governor as arranged. The
investigator also met the Deputy Governor, the prison’s liaison officer to the
investigator, a representative of the Independent Monitoring Board, a
representative of the local Prison Officers Association, the Devon PCT
Patient Safety Quality Manager for Commissioning, the Healthcare
Services Governor for Devon Partnership andthe prison coordinating
chaplain.
3. Following the meeting, the investigator and the healthcare team went to the
cell where the man had been found hanged. They were able to view the
inside of the cell and see where the ligature was attached. After viewing
the cell, the investigator arranged to return at a later date, to continue with
the investigation.
4. In February, the investigator returned to the prison to begin interviewing
staff. At the end of the week, he met with the Governor and gave feedback
about his initial findings and likely recommendations. He later followed this
up in writing. Before leaving the prison, he arranged to return at a later
date to carry out joint interviews with the clinical reviewer.
5. Four days later, the Ombudsman’s family liaison officer spoke to the man’s
mother who was his listed next of kin. This was to inform her about the
investigation and provide her with an opportunity to raise any concerns or
issues she wished to be explored as part of the investigation. His mother
raised a number of issues including wanting to know why her son was able
to take his own life, given that he was being monitored. Additionally, she
was concerned that his medication had been changed whilst in prison and
had tried to discuss the issue with prison staff. His mother said that when
she telephoned the healthcare department, she was told they could not
discuss it due to patient confidentially.
6. His mother said she had spoken to her son on the day he died and
described him as being exhausted. She asked whether prison staff tried to
help him. Additionally she asked why he was moved from healthcare to a
prison wing and whether prison staff had recognised his distress.
7. The investigator has considered and attempts to answer these questions
within the report. I am very grateful to the man’s mother for her assistance
at what was a very difficult time. A copy of this report will be shared with
his family. I hope the findings of this investigation help them better
understand the events leading to his death.
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8. In April, the investigator returned to Dartmoor with the clinical reviewer to
continue his interviews. The clinical reviewer was assisted by a Consultant
Psychiatrist. The following day, the investigator fed back his findings to the
Deputy Governor, and followed this up by writing to the Governor
explaining what he had told the Deputy Governor. At the time of writing this
report, I have not received a response to the feedback from the Governor.
9. As part of the normal process for investigating deaths in custody, a clinical
review report was requested from the local Primary Care Trust, and they
commissioned a clinical reviewer. In July, the investigator received the
report.
10. In preparation for this investigation the Clinical Lead, Devon Prisons Health
Partnership, submitted a report to the investigator for inclusion in the
investigation. I have used some of the information from his report to help
fill in any gaps in the clinical review report.
11. After issuing the draft report, I received feedback from the Prison Service.
They told me that with the exception of one, all recommendations had been
accepted. The Prison Service did not feel it necessary to make clearer the
transfer arrangements between Dartmoor and Exeter or to provide clear
care plans in the medical records.
12. Additionally, I received feedback from the man’s mother. In her response
to the draft report, she said she was concerned that staff had not entered
his cell straight away, particularly given his long history of mental health
problems. She also reiterated her concerns about changes to his
medication, in particular a reduced dose of diazepam.
13. The man’s mother added that she was concerned that he had been asked,
rather than being told to move to a safer cell. Additionally, she said prison
staff should have varied the times of observations. She said she felt it
unsatisfactory that the prison had been unable to accommodate him
properly. She said she was satisfied with the report and agreed with the
recommendations.
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HMP DARTMOOR
14. The prison is situated close to the village of Princetown in Devon.
Originally built in 1809, the prison has undergone extensive refurbishment
and modernisation. Accommodation is provided for adult sentenced males.
Her Majesty’s Chief Inspector of Prisons
15. Her Majesty’s Chief Inspector of Prisons reports on all prison
establishments. The majority of inspections are announced and allow the
prison being reported on to prepare for inspection.
16. In the introduction to her latest report on Dartmoor, following an announced
inspection during 11 – 15 February 2008, she said it was disappointing that
the inspection found that progress identified previously had not been
maintained and that the prison had slipped back noticeably. However, she
acknowledged that it was still considerably better than it had been in 2001.
17. She went on to say that the prison was not unsafe. She said that with the
exception of one wing (A wing), the inspectors found staff who were
engaged, committed and often overworked.
18. In the final paragraph she said:
“It is always disappointing to report on a prison which has not been
able to maintain promising progress. Dartmoor had significantly
slipped back from the prison we inspected in 2006. It will require
renewed and much more robust management to reverse this trend, to
support and encourage committed staff, and to ensure that Dartmoor
once again fulfils its role as an effective training prison”.
19. Within the main report, she said vulnerable prisoners were held on F and G
wings. She said prisoners there said they felt safe and that staff were
generally helpful. She added that staff appeared aware of potential bullying
and risks and that “Staff – prisoner relationships were mixed, but
insufficiently proactive, except on the resettlement and vulnerable prisoner
wings”.
20. Under the heading of self harm and suicide, she said there was an
appropriate system to manage self harm and suicide, but the quality of
interventions varied across the prison. She said the information was not
well reviewed during safer custody meetings and that management checks
did not include an assessment of quality. She went on to make seven
recommendations.
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21. In relation to health services, she said that mental health provision was
satisfactory, but there was a lack of multidisciplinary working. She went on
to say there was no formal mental health awareness training for prison
staff. She made 19 recommendations about health provision.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) made up of
members of the public and their role is to monitor the prison and to report
any concerns that they have regarding the prison, or how prisoners are
treated. In the first instance, the Board report to the Governor, or, if
considered necessary, it can report directly to Parliament. Board members
are able to visit any area of the prison at any time and have direct access to
any prisoner who they wish to see, or who requests to see them. The
Board holds regular meetings in the prison, with the Governor attending for
part of the meeting. The Chairperson of the Board produces an annual
report to the Secretary of State for Justice.
23. In its latest report, covering the period from 1 October 2008 – 30
September 2009, the Board said that in the first quarter of the reporting
year, the prison continued to perform poorly and had dropped from a level
three prison, to two. (The National Offender Management Service rates
prisons using four levels, with level four being the highest and best
performing.) However, following the arrival of the Governor, the Board
were pleased to note that the performance had gone back up to three. The
Board went on to say that the appointment of the Governor had brought
strong leadership and that he was developing a clear strategy for the prison
and challenging unacceptable behaviour.
24. Under the heading of mental health issues the Board said
“Probably the biggest challenge faced in regard to diversity is the
acceptance and understanding of staff in how to respond to those
prisoners who have mental health issues.
There is an overarching assumption that all prisoners can be expected
to and should respond in a similar way. Training is required to
challenge these assumptions. An awareness in how to deal with
different mental health conditions…
Mental health interventions provided through healthcare are severely
reduced at present”.
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Healthcare provision
25. Dartmoor forms part of the healthcare cluster between Exeter and HMP
Channings Wood. Neither Dartmoor nor Channings Wood has any facilities
to care for prisoners requiring a hospital bed. In cases where a prisoner
requires a hospital bed either because they are ill, or require constant
observation, there is a protocol in place which allows for prisoners to be
transferred to Exeter healthcare.
26. The Clinical Lead is based at Exeter and is the Clinical General Practitioner
Lead for the Cluster. He oversees the protocol for all three prisons. He
attends Dartmoor on Mondays remaining there all day, whilst on Fridays he
attends for the morning only. For the remainder of the week, doctor cover
at Dartmoor is carried out by locums.
27. At the time of the man’s death there were nine general nurses and two
healthcare assistants at Dartmoor. Included within the nine general nurses
were three mental health nurses. Additionally, there was a visiting nurse
specifically employed to work with prisoners with learning difficulties.
Assessment, Care in Custody and Teamwork (ACCT)
28. ACCT requires staff to identify any concerns, take action, and document
those actions for prisoners identified as at risk of suicide or self-harm. The
ACCT document should be available to all staff where the prisoner is
located. Within 24 hours of the document being opened, the at-risk
prisoner will be interviewed by a trained ACCT assessor. The ACCT
assessment section has eight questions which are used as a reminder to
the assessor of areas to be covered. The assessor’s role is to consider the
questions and if necessary expand the questioning, recording their
comments in the ACCT document. Following the assessment a case
review meeting is held, which is a multi disciplinary meeting and meant to
involve sufficient numbers of staff to make an informed decision. The
meeting draws up a care and management plan, known as a CAREMAP,
and a member of staff is nominated as the case manager. Wing managers
take on the role of case manager, oversee the management of the ACCT
document and attend case reviews. Regular case reviews are held until it
is felt the prisoner is no longer at risk and that the ACCT document can be
finally closed. In the meantime, prisoners are monitored. Monitoring can
be anything from constant observation to intermittent.
Care team
29. Each prison has its own care team. Care team staff are drawn from all
areas of the prison and trained specifically to help and support prison staff.
Following any serious incident, they provide an invaluable role to any
member of staff who requires support.
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Emergency response codes
30. In the event of urgent medical assistance being required, a number of
prisons have chosen to adopt codes to alert medical staff to particular
incidents. The most common code used is code red and code blue,
although some prisons have opted for code one and code two.
31. Code red or one informs the medical staff that the patient is bleeding.
Code blue or code two alerts them that the patient is in breathing difficulty.
At Dartmoor the code used is red and blue.
32. In prisons where codes are used the healthcare departments have created
emergency response bags which contain the necessary equipment to deal
with the particular incident. This ensures that medical staff takes the
correct emergency equipment with them and helps provide the necessary
medical care as quickly as possible.
Police investigations of deaths in custody
33. With all deaths in prison custody, the police are notified by the prison as
soon as the death has been discovered. In the first instance, the police
treat the area where the person is found as a potential crime scene and, as
part of their investigation, note the names of everyone involved and those
who have been in contact with the body. Additionally, they note the identity
of all those entering and leaving the cordoned area. It is only when the
police are satisfied that the death is not suspicious that the Ombudsman’s
investigators begin their own investigations.
34. At the meeting with the investigator in February, the officers confirmed that
the man’s death was not being treated as suspicious and that no final note
had been found in his cell. The officers also agreed that the investigator
could enter the man’s cell for the purpose of familiarising himself with the
layout. The investigator shared with the officers a copy of the
Memorandum of Understanding between the Ombudsman and the
Association of Chief Police Officers.
Prison officer grades
35. There are three levels of uniformed prison officer grades. Prison officers
are the front-line supervisory staff and, in the majority of cases, prisoners
have first and most contact with them.
36. Senior Officers (SOs) are the first grade of managers and act as a
reference point for prison officers. SOs are responsible for the day-to-day
management of their area, supervising staff and dealing with issues raised
by prisoners.
37. Principal Officers (POs) are the highest rank of the uniformed staff. They
supervise other uniformed staff and have operational responsibility for the
prison.
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38. In addition to prison officers, there are a group of staff known as
Operational Support Grades (OSGs). OSGs wear prison uniform and carry
keys but do not carry out the same function as prison officers. Their role is
to support the areas of the prison that have little or no prisoner contact, for
example, the gate. Additionally, they carry out night patrol duties. These
duties often mean they have indirect contact with prisoners, which is limited
to seeing and talking to them through a hatch in a cell door.
Prison Service Orders (PSO)
39. At the time of the man’s death, Prison Service Orders were in use. They
contain long term mandatory instructions which are intended to last for an
indefinite period. Any mandatory instructions to Governors or Directors of
contracted prisons are written in italics. Each PSO is given a title and
unique reference number.
PSO 2700. Suicide Prevention and Self Harm Management
40. PSO 2700 provides instructions on identifying prisoners at risk of suicide
and self harm, and on providing the subsequent care and support for
prisoners. Included within the PSO are mandatory instructions, with an
implementation date of 30 April 2008.
Personal Issue Cut-down tool (PSO 2700 section 11.3.3) “Fish Knife”
41. Contained within PSO 2700 is the following mandatory instruction:
“All unified and uniformed staff in closed and semi-open establishments
must be provided with and carry on duty their own personal issue cut-
down tool.”
42. Personal issue cut down tools are specially designed anti ligature knives,
commonly referred to as “fish knives” because of their shape, which are
used in an emergency to remove a ligature. The knives have a concealed
blade which is placed against a ligature and which can be pushed forward
to cut it without harming the prisoner.
Safe Cells
43. Although not a recognised term by the National Offender Management
Service, Dartmoor has five cells that they call “safe cells”. The cells are
designed to have fewer ligature points and furniture with rounded edges.
They are intended to be used as a short term method of supporting
prisoners who are at risk of harming themselves. Once the prisoner is no
longer deemed to be at risk, they return their own cell and the safe cell is
expected to remain empty and available for use as necessary.
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Sealed cell key
44. Unlike the officers on duty during the day time periods, night patrol officers
are not issued with any security keys. Instead, they are issued with a cell
key, which is kept secure in a sealed leather pouch, secured to the officer
and only opened in the event of an urgent need to enter a cell. The officer
must first of all be satisfied that it is safe to unlock the door and enter the
cell. If they judge that it is not safe, then they must wait for assistance to
arrive.
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KEY FINDINGS
July 2008
45. In July, the man transferred from HMP Gloucester to Dartmoor. In his
clinical review, the clinical reviewer said there was an appropriate
healthcare screen carried out when he arrived at Dartmoor. It had been
noted that the man had been diagnosed as suffering from paranoid
schizophrenia for which he had been prescribed olanzapine, Venlafaxine
and Diazepam.
46. In his report, the Clinical Lead said that when the man arrived at the prison,
he was on a reducing dose of Diazepam. He added there had been a
lengthy discussion with the man about reducing the medication, although
he does not say who it was that had spoken to him.
47. Whilst in Gloucester, the man had been assessed by the psychiatric in-
reach team and arrangements had been made for his case to be reviewed
by the Dartmoor team. In August, the man was seen by a member of the
in-reach team at Dartmoor and a gradual withdrawal from Diazepam was
recommended.
48. The clinical reviewer said the man had been well up to September.
However, when he was seen and assessed by Consultant Psychiatrist that
day, he noted that his paranoid ideas had become more troublesome. The
doctor noted him as being “low in mood, but having no suicidal thoughts”.
The Consultant Psychiatrist adjusted the man’s medication and started him
on a course of Risperidone, an antipsychotic drug. The following month, a
further review was carried out and the Risperidone dosage increased.
49. In October, the man harmed himself by cutting his wrist. He was assessed
by prison healthcare staff and his injuries treated. As a result of the self
harm and him telling the officer that he would “dangle himself”, he was
moved to a safe cell and an ACCT document opened and monitoring
started. The level of monitoring was set at twice hourly. He told the officer
that he was hearing voices and that staff and prisoners were laughing at
him. (The document remained open through to the time of his death.)
50. At the ACCT assessment interview carried out the next day, the man said
he felt everyone was talking about him and that he was hearing voices. He
said that cutting his left wrist was a genuine attempt to end his life. It is
noted in the assessment section that he was feeling low and had broken
down in tears during the meeting. He was apparently observed shaking
and repeating that the voices made his head hurt. He went on to say that
he planned to hang himself from the cell window bars and that he wanted to
go to sleep and not wake up.
51. During the assessment, the man was seen by the Clinical Lead. The
doctor assessed him as being “very paranoid” and arranged for him to be
13
transferred to HMP Exeter that day as an in patient. The reason for the
transfer was so that his condition could be stabilised.
52. In October, the man was assessed by members of Exeter’s medical team
with a view to returning him to Dartmoor. A psychiatric review took place
and recommended that he remain at Exeter due to his deteriorating mental
state and increased risk of harming himself.
53. The clinical reviewer said that the man’s medical record notes that
healthcare nursing staff had recorded him as being settled. The doctor said
this was in direct contrast to psychiatric nurses who had written that the
man was “quite paranoid and unwell”.
54. In November, a further psychiatric review took place. The Exeter
psychiatric in-reach team decided that the man’s mental state had
deteriorated to the point where admission to an external hospital should be
considered. Before organising admission, they asked his previous in-reach
team from Gloucester to see him.
55. The next day, the first ACCT case review took place attended by two
members of staff and the man. The ACCT record notes that he was
emotional and tearful during the review and as a precaution he was placed
on “intermittent supervision” and remained in the healthcare unit.
56. In his report, the Clinical Lead said that, in November, the man had been
seen by a Consultant Psychiatrist. He said the Consultant Psychiatrist
adjusted the man’s medication, increasing the dosage of the Venlafaxine
and, starting him on Quetiapine an antipsychotic drug whilst stopping the
Risperidone.
57. In November, a second ACCT case review was held. Once again the man
attended the review and was noticeably tearful and anxious about his
future. It was noted in the ACCT document that he had a fear of not getting
better. The case manager also noted that the man had good insight into
his illness and was complying with his medication regime. The level of
observation remained unchanged at intermittent.
58. Seven days later, the third ACCT case review was held. On this occasion
the man was recorded as saying he felt settled at that time and was much
more confident. The case manager said the man felt able to interact with
staff and peers and kept the level of observation as intermittent. He told
the case manager that he had no thoughts of harming himself and was
looking forward to the future.
59. In November, as a result of the request made earlier in the month, a
Consultant Psychiatrist reviewed the man. His assessment of the man’s
condition was:
(cid:127) “Chronic schizophrenia with some ongoing symptoms
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(cid:127) Chronic substance misuse. (Currently abstinent in a controlled
environment.)
(cid:127) Current risk of suicide considered low. However, the doctor added that
the man’s history predicted a long term risk of impulsive deliberate self
harm at times of stress.”
60. The Consultant Psychiatrist said that, in his medical opinion, he did not
consider that the man required admission to hospital. He said he appeared
to be taking his medication. Additionally, the doctor considered the risk of
suicide as low. The doctor increased the Quetiapine prescription to the
maximum recommended level. In his clinical review, the clinical reviewer
said the prescription appears to have been slow in being actioned, as it was
not supplied until November, three days after being authorised.
61. In November, the fourth ACCT case review was held. The case manager
noted that the man was continuing to take his prescribed medication. He
went on to say that he was aware of the signs and symptoms related to his
illness. It was also noted that he had said he was “feeling a bit paranoid”,
but had no thoughts of harming himself. The case manager left the level of
monitoring as intermittent.
62. The nursing entries in the man’s medical record describe a settled period.
In December, following a mental health review, it was thought that he had
recovered sufficiently for him to be transferred back to Dartmoor. It was
also noted that he should be allocated to a vulnerable wing as it was
thought he might relapse if not. (Vulnerable wings are normally used to
accommodate prisoners who, due to their offence, may be at risk from
other prisoners. They are also used to accommodate prisoners who might
be susceptible to bullying or have difficulty coping in prison. Vulnerable
wings are generally much quieter and offer a more relaxed calming
atmosphere, which is why it was recommended for him.)
63. In December, the fifth ACCT case review took place. The case manager
wrote a positive summary of the meeting. In it, he describes the ma as
focusing positively on his future and gaining confidence. As before, the
level of observation remained as intermittent.
64. Eight days later a further ACCT case review was held. Like the one held
the previous week, the summary was positive in that the man’s confidence
had increased and he was able to interact. Similarly, the seventh case
review held noted that he was settled and sociable. At the end of the
review, another was arranged for January 2009, with the level of
observation remaining as intermittent.
65. In the meantime and, before arranging the transfer back to Dartmoor, the
prison was contacted to ensure they were able to take the man. At that
point, the vulnerable wing at Dartmoor prison was full and so Exeter was
asked to allow him to remain there until after the New Year, which was
agreed.
15
2009
66. In January, an ACCT case review meeting was held. At that meeting it was
noted that the man had been upset when told that his mother had
telephoned the prison enquiring how he was. He became tearful and it was
noted that he was not doing as well as he had been presenting. It was
agreed that he should be seen by an in-reach worker and that the level of
observation remain as intermittent. Also discussed was whether his
transfer back to Dartmoor should be deferred.
67. The following day, a Registered Mental Nurse saw the man and recorded in
his medical notes that he wanted to die. He had told the nurse that he had
been looking for ligature points in his cell and had said he would make a
noose.
68. In his clinical review, the clinical reviewer said a psychiatric review was
arranged by the Consultant Psychiatrist who in turn arranged for a twice
weekly psychiatric review. The clinical reviewer adds that in January, the
man’s medication was increased. He points out that, despite this, the
Clinical Lead had written in the man’s medical notes “Awaits transfer to
Dartmoor”.
69. In January, another ACCT case review meeting was held. The man was
described as having a positive and settled attitude, but was concerned
about the possibility of relapsing. The level of observation remained as
intermittent.
70. The clinical reviewer said that by January, the man’s medical notes refer to
him as being settled and that his paranoid ideas were declining. However
he adds that the nurse had made an entry to say that the stress of returning
to Dartmoor may cause a relapse, but felt the additional support would aid
his recovery.
71. The final entry in the medical notes, before the man returned to Dartmoor,
was made by the nurse. She said that he was allegedly secreting
medication. The file does not say who was making the allegation. At
interview, the nurse said the man had not taken his medication as he had a
stomach upset and had not been storing medication. She added that he
was reminded of the importance in taking his prescription.
72. In January, two ACCT case reviews were held, with the first one being at
9.25am whilst at Exeter, the second was held at Dartmoor. At the first
review, it was noted that he was nervous about returning to Dartmoor. The
case review manager added that he was not thinking about harming
himself. He made a note to say that the ma was experiencing some mental
health issues, but does not say what they were. He went on to say that
they were not as severe as those he had experienced previously. The man
agreed to continue with the support of in-reach and was reminded of the
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need to take his medication. It was agreed that the level of observation
should remain as intermittent.
73. Later that morning, the man returned to Dartmoor. When he arrived there
he was seen by one of the healthcare staff. She made a note in his
medical file which said he was happy to be back at the prison.
74. Another person to see him that day was an officer. The officer said he met
the man as part of the normal procedure for settling new prisoners into the
wing. As well as this and along with another officer, a further ACCT review
was carried out. The man attended the review meeting and asked if the
ACCT document could be closed. The officer told the investigator that the
request was declined as it was felt a further assessment should be carried
out. He said the man accepted the decision and was calm throughout the
meeting. He left the level of observation as intermittent.
75. Four days later, in January, the man attended another ACCT case review.
The case manager summarised the meeting saying that the man was “very
relaxed”. The manager noted that he said he was relieved to have been
allocated to the vulnerable prisoner unit and had settled in well. It was also
recorded that he was still in contact with in-reach.
January
76. In January, the man was expected to attend a doctor’s appointment, but did
not attend. The clinical reviewer is unable to say why he failed to attend
the appointment, but notes that a new appointment was made. He also did
not collect his morning medication from the prison dispensary and it is
recorded in his medical notes that he refused to take his medication.
77. During the early part of the afternoon and shortly before making a
telephone call, the man approached an officer, who was in the wing office.
He began talking to the officer about his medication. Although initially calm,
his voice became louder and louder. He told the officer that the doctors
and his own family wanted to kill him.
78. Prison telephone records show that at about 2.30pm, the man made the
first of four telephone calls. As there was no requirement to monitor his
telephone call, he was able to make normal telephone calls. The call lasted
for just under seven minutes. The investigator has listened to the
conversations and summarised the content.
79. The investigator believes the call was answered by the man’s mother. The
man spoke very quietly and told her that he was exhausted and that he
“had had enough”. After a few minutes, the call was passed to another
female, believed to be his grandmother. He spoke mainly about his
medication and told the lady that he was due to see a doctor the following
day. He repeated that he had had enough and said he had “told them”. He
also complained about lack of sleep.
17
80. The man told his grandmother that when he first went into prison he was
fine, but then adds that his medication was being “messed with” and said
he was paranoid. She suggested that he should see a doctor and he
replied saying “they are all in it”. He went on to say that he has “horrible
feelings and paranoid”.
81. During the conversation, the man said he was going to “string himself up”.
He again said that he had had enough. At this time, his voice has became
raised and agitated, with his language becoming abusive. He went on to
say that he was going to “smash up” and that he had “gone weird”.
82. At this point, his mother returned to the telephone. The man was still
aggressive, kept repeating himself over and over and was asked to calm
down. He described his feelings, and once again said he would “string
himself up”. He then said that he felt trapped and was “too scared to
move”. He ended the call abruptly by saying he did not know if he would
telephone again.
83. The man made his second telephone call at 3.16pm to a different number,
with the call lasting for four and a half minutes. The remaining two were
made to the same telephone number.
84. The telephone call was answered by a lady and begins by a general
discussion regarding a letter. After a short time, the man said that he had
had enough and said he did not “feel right”. He repeated what he had said
in his earlier call and said he would smash up his cell. The woman asked
him if he was taking anything for his paranoia, and he said that he was not,
adding that he was not eating. He told her that his medication was not for
the treatment of paranoia. He went on to say that he would string himself
up and that there were 130 people in the wing talking about him. He said
he was unable to take any more and that he could not speak to anyone in
the prison. Once again, he said he would smash up his cell and go to the
segregation unit adding that “there was no one to talk about him”. He also
said he felt trapped. The woman asked him if he was taking valium. At his
point he ended the call saying she and his mother were “probably in it as
well”, he then replaced the handset.
85. Shortly after, two officers went to the man’s cell to speak to him. At
interview, one officer said the man told him that he was a paranoid
schizophrenic and healthcare staff were “messing with his medication”.
The man went on to say he had read an article in a magazine, which told
him that his medication was for the treatment of bi-polar disorder. The
officer said he then showed him the article. The officer said the man had
misread the article and it was in fact written about the treatment for those
who have used LSD.
86. The officer handed the investigator a report which he had prepared
following the man’s death. He said he had made the note the following
day. In his report, the officer noted that throughout the conversation the
man was displaying mood swings. He said the man alternated between
18
talking quietly and then shouting, becoming excited and tense. He told the
officer how he was feeling. The officer noted that he said “I feel like all the
stuff is pouring out of me, everyone is talking and laughing at me, do you
think I like feeling like this”. The officer went on to say that the man would
turn his head away and ignore him if he or the other officer were not saying
what he wanted to hear. The officer also noted that he said “you want me
to commit suicide, well I will”. The officers told him that they would arrange
for him to be seen by a nurse, which the officer said had the effect of
calming him down.
87. After about 30 minutes, the officers left the man’s cell and went to
healthcare and spoke to a nurse. At that time the nurse had a patient with
her. They interrupted her and asked if she would see him as soon as she
was finished. Both officers then returned to F wing.
88. At 3.42pm, the man made a third telephone call, which was answered by
another woman. He told her that his medication was for the treatment of bi-
polar disorder and not paranoia. He said that he had stopped taking his
medication saying it was a “conspiracy”. He said he was unable to speak
to anyone as “they” were all talking about him. The woman told him “not to
do anything silly”. He told her he was unable to take any more and wanted
to talk to someone, but “they were all in it together”. He said “they do not
want me to get better” and at this point he ended the call abruptly.
89. At about 3.45pm, the nurse arrived at the wing regarding an unrelated
matter. The two officers saw her and took the opportunity of speaking to
her again about their concerns for the man. In his report, the officer said
the nurse asked them to take him to the treatment room, but to allow her
about ten minutes so that she could read his medical record before meeting
him.
90. About 15 minutes later, the officers took the man to the treatment room. In
his report, the officer noted that the nurse saw the man, but once again his
mood swings were evident. The officer said the nurse showed the man a
copy of the British National Formulary (which lists prescribed medications)
and the section relating to the medication that he had been prescribed.
The officer said he read the document and then became angry, saying the
staff were against him, after which he left the room and returned to his cell.
91. In his report, the officer said that he and the other officer decided to speak
to the wing manager and the SO. He said they told both managers of their
concerns and it was decided that the SO would hold an ACCT case review
meeting to discuss the man later that day.
92. At interview, the SO said that at about 4.30pm he went to speak to the man
about his behaviour as he had been told that he was aggressive towards
staff. He went to his cell and spent about ten minutes talking to him. The
SO said he was complaining about his medication, saying that the
treatment was wrong. He showed the SO the same article that he had
earlier shown to the officers. The SO told the investigator that the article
19
had appeared in a magazine called FHM. He said the man showed him a
section in the magazine relating to the same type of medication that had
been prescribed to him. The SO said the man told him that the report
stated that the medication was for the treatment of bi-polar disorder. The
SO said the reason for the man being angry was because he was not bi-
polar and that he believed healthcare had deliberately given him the wrong
treatment.
93. After speaking to the man, the SO decided that he needed to leave the cell
and seek further advice. He said that when he left the cell, the man was
much calmer.
94. Having left the cell, the SO spoke to the nurse and the officer about holding
an ACCT case review meeting. The SO said the nurse told him that she
would speak to someone in HMP Exeter healthcare, because the man had
a mental health issue and she wanted to see if they would take him back.
95. In his clinical review, the clinical reviewer said the man had been
expressing a view that all nursing and medical staff were against him and
that he wanted to kill himself. He adds that, although she had no mental
health training, the nurse tried to explain to him what his medication was
used for.
96. At interview, the nurse said she telephoned the healthcare department at
Exeter to enquire whether they had a bed available for the man. She said
the person she spoke to felt it unlikely, as they were expecting new
prisoners.
97. The nurse tried to contact the Clinical Lead for his advice. When she
eventually made contact with him, the doctor said he would review the man
the next day, but said he felt he would be all right overnight. However, in
his report, he said:
“… if the condition necessitated and she was very concerned regarding
self harm he [should] be admitted to the healthcare unit at Exeter”.
98. Following her conversation with the Clinical Lead, the nurse recommended
that the level of ACCT observations be increased to maximum, which she
said was every 15 minutes. She also recommended that an ACCT review
should take place the next day.
99. In the meantime, the SO read the man’s ACCT document. At interview he
said the purpose for doing this was to read the entry of the previous case
review and the reason why he was subject to ACCT monitoring.
100. At about 5.30pm, the SO went to speak to the man about the case review.
The SO asked him if he had used the telephone which he confirmed,
saying that he had spent about ten pounds on the telephone. The SO
asked him who he had spoken to and what he had talked about. He told
him that he had spoken to his friends and his sister. The SO asked him if
20
he had spoken to his parents. He said he had not as they did not get on.
He also told the SO that he was looking forward to being released in four
months. He then said “don’t worry I will not be a problem to you tomorrow”.
The SO asked him to explain what he meant and was told that he was
intending to “smash up” his cell with a view to getting out of Dartmoor.
101. The SO said he spoke to the man about the possible consequences of his
actions. He tried to persuade him that it would be better to remain where
he was, as he would have access to every day items such as television.
They also discussed the possibility of him being moved into a safe cell
within the wing and increasing the level of observations. The SO said the
man resisted the idea of moving and told him that he would have to be
forcibly moved into a safe cell. The SO said the man appeared to
understand why he was suggesting a move of cell and increased ACCT
observations, but that he was unhappy with the prospect. He went on to
say that the man felt healthcare staff were against him.
102. After leaving the cell, the SO spoke again to the nurse. She told him that
Exeter would not take the man back, as the prison was full.
103. In the meantime, at 6.19pm, the man made what was to be his final
telephone call. The call was answered by a man and the man asked for a
woman. He told her that he had spoken to staff about his medication and
also that his purchases from the prison shop were wrong, adding that it was
all a “conspiracy”.
104. At this point the man became much angrier, saying he would be taken to
the segregation unit. He began shouting and, from what could be heard in
the background, it would appear that he was being abusive to someone in
the wing. The man said people were shouting and that it echoed in his
ears. He said he had had enough, could not sleep and was exhausted.
105. Towards the end of the conversation, the woman asked the man to
telephone his mother. He said no and told her that this was the last
telephone call he would be making. The call was then taken over by the
man who originally answered. The man began to repeat himself and talk
about his medication. The man tried to reason with him and told him to
concentrate on his artwork. The man talked over him and said “tell Lisa I
love her”. At that point, after seven minutes and 23 seconds from when the
call began, it was terminated by the man.
106. As part of this investigation, the clinical reviewer and his assistant have
listened to the telephone calls. In his clinical review, he said:
“… it is clear he was feeling isolated and his thought processes were
deteriorating quite quickly over this time. He also had lost confidence
in the doctors who were looking after him. Despite pleas from his
family to talk to the staff about his worries, the man did not do so.”
21
107. The SO told the investigator that, before organising the ACCT case review
meeting, he sought advice from the prison Suicide Prevention Co-ordinator.
He said the purpose of speaking to him was to discuss what options were
available. The SO told him that the man was refusing to move to a safe cell
and so he wanted the Co-ordinator’s opinion on the level of observations
appropriate to the man’s needs. The SO went on to say that the man told
him that he did not want an increase in observation levels because he said
he was a paranoid schizophrenic. The SO said the man felt that people
would be looking at him which he felt would make him even more alarmed.
108. After speaking to the Co-ordinator, the SO returned to the man’s cell to
discuss the arrangements for the review. He told the SO that he did not
want to leave his cell because he did not like people. He said he did not
like being looked at and that the wing was too big for him. The SO said the
man told him that he did not like the unit and wanted to get out of the
prison. During the conversation, the SO attempted to engage further with
him by suggesting he played a game of pool or chess. However, although
he appeared to appreciate what was being said to him, he repeated his
wish to leave Dartmoor.
109. In the meantime, the Co-ordinator considered what options were available
to keep the man safe. His first thought was to move him to cell G 106,
which the SO said was a safe cell, although he was unsure whether he
would move willingly. Due to his uncertainty, the SO looked at PSO 2700
to see if it contained any information about moving someone by force if
necessary. He said he was unable to find any information to advise him.
The Co-ordinator went on to say that he later discovered that cell G 106
was unavailable as another prisoner was located there. He said the
prisoner in the cell was not “at risk” and he was there was because a
decision had been taken to use the safe cells as part of the Certified
Normal Accommodation (CNA) figures. (CNA is the minimum amount of
bed space available in the prison.) He said he did not know who had made
the decision, but added that following the man’s death, the Governor had
removed the safe cells from the CNA. I deal with this later in the report.
110. One of the options available was for the man to be monitored constantly by
a member of staff outside his cell. The investigator asked the Co-ordinator
if this was something which had been considered and whether to do so
would cause operational difficulties. He said it would cause problems
because an extra officer would have to be called in to sit outside the cell.
Additionally, he said there is no facility at Dartmoor for constant watch and
anyone requiring such a level of observation would require an immediate
transfer to Exeter healthcare. He went on to say there is no gated cell
facility at Dartmoor, or clear fronted gated cell where somebody can be
observed constantly and no 24 hour healthcare facility available at the
prison. (A gated cell is one with bars which does not obscure the view,
rather than a solid door, which does.)
111. The investigator asked the Co-ordinator what the scenario would be if,
during the night, there was an urgent need to monitor a prisoner who
22
required constant observation, but could not be moved straight away to
Exeter. He said he would have to call in an extra member of staff to cover
the work.
112. At about 7.25pm and what was to be the final ACCT case review meeting
took place, which the man attended. Chairing that meeting as case
manager was the SO and also present were the nurse Harris, the officer
Denny and the Co-ordinator.
113. In the case review summary, the SO noted that the man had been
“unwilling to engage” in the review until they went to his cell. He told them
that there was a conspiracy against him and said healthcare “were playing
with his medication”. When asked if he felt suicidal, he did not answer.
However, he did say “don’t worry you will not have a problem tomorrow”.
Although it was recorded in the review that the panel were concerned at
what he had said, they felt he was trying to manipulate the situation. As a
precaution and due to him having previous a history of cutting himself, the
SO suggested that the cell should be checked and any razor blades
removed. (Prisoners are allowed to have razor blades unless it has been
decided that they should not. In this case, he was allowed to have a razor
blade in his possession.) The level of ACCT observations was increased
from intermittent to hourly. A further case review meeting was scheduled.
114. At about 7.45pm, an OSG began her duty in F wing as the night patrol
officer. Also starting duty at a similar time was a night officer. She was the
night patrol officer on G wing, which is adjacent to F wing, and jointly they
were responsible for G and F wings.
115. At interview, the night officer said that when she arrived into the wing, she
did so at the same time as officers were going into the man’s cell to remove
his razor blades. The officer said she was told that the level of ACCT
observations on him had been increased to hourly. The night officer went
on to say that, before the day staff left the wing for the evening, she asked
one of the officers what his mood was. She said an officer told her that he
was fine.
116. The OSG said that when she arrived into F wing, the SO told her that the
level of observations on the man had been increased to hourly. Having
received a handover from the SO, she began her patrol.
117. At about 8.00pm as part of the ACCT monitoring, the OSG looked into the
man’s cell and saw him. She said he did not speak to her, as he was using
the toilet. About an hour later the OSG carried out a further ACCT
observation and on this occasion he was watching television.
118. The next ACCT observation was carried out at 10.00pm by the night officer.
At interview she said when she looked into the cell the man was watching
television. She said she spoke to him and he said he was okay. The
investigator asked the officer if she had any concerns about him at that
time, and she said that she did not.
23
119. One hour later, at 11.00pm, the OSG made a further ACCT observation.
She said the man was still watching television and, although he did not
speak, he did look at her. This would appear to be the final occasion that
he was seen alive.
January
120. At about midnight, the night officer went to the man’s cell to carry out the
next ACCT observation. When she looked into the cell, she saw his face
squashed against the door observation glass. The officer said there was a
green sheet around his neck.
121. Unsure about what she had seen, the officer went to the wing office and
asked the OSG to assist her. Before returning to the cell, the OSG used
her prison radio and asked the radio operator to contact the night manager
for his assistance. Satisfied that help was on the way, she and the night
officer went to the man’s cell.
122. When they arrived at the cell, the OSG unlocked the cell door. However,
as they were unsure about whether the situation was real or not, they did
not go inside, deciding to wait for assistance. At interview, the OSG said
the man’s skin colour was grey and there was no movement. She said her
instinct was that he was dead.
123. Following the request for assistance, the radio operator asked the night
manager to go immediately to F wing. The operator told the night manager
that a prisoner was hanging.
124. The night manager was an Acting Senior Officer (ASO). At interview, the
ASO said he began making his way to F wing and as he was doing so, he
received a further message from the radio operator. The radio operator
asked for permission to break the emergency cell key seals and gate key
seals, which he agreed to.
125. As well as the ASO hearing the message, all those on duty with a radio
heard the request for assistance. One of those was an officer. At
interview, the officer said that when he heard the radio message he did not
hear what was happening as there was a lot of background noise. Sensing
that something was wrong, he asked the radio operator if he was required
and was told of the situation in F wing. The officer then made his way to
the wing.
126. When he arrived he saw the night officer and OSG outside the man’s cell
and could see his face against the observation glass. As his body was
against the door, the officer had difficulty opening it and had to push at the
door to gain entry.
127. The officer said that, when he went inside the cell he realised that the man
was hanging. A ligature was round his neck and had been attached to the
24
window bars. The officer took the weight off the ligature by lifting and
supporting his body. Following him into the cell was the night officer, who
used her anti ligature knife to cut the ligature. Once it had been cut, they
laid him onto his back, and began checking for signs of life.
128. Those checks included pinching the man’s ears and listening for his
breathing, although they did not check for a pulse. The officer said the
man’s skin was clammy and colder than what would normally be expected
of someone alive.
129. Unable to detect any signs of life, both officers began Cardio Pulmonary
Resuscitation (CPR) at a ratio of 30 breaths to two chest compressions,
which is the correct procedure. Although he had a mouth guard, the officer
felt it hindered his ability to perform CPR and so discarded it, preferring
instead to give direct mouth to mouth breathing. He said he could see the
man’s chest rising and falling as he did so. Whilst he was performing
mouth to mouth resuscitation, the night officer administered the chest
compressions.
130. In the meantime, the ASO had arrived into the wing, where he met the
OSG. She told him that it was the man who had been found hanging and
then directed him to his cell. When he got to the cell he saw both officers
performing CPR.
131. The ASO told the investigator that the night officer was tiring as a result of
doing the chest compressions and so he took over from her. The ASO and
the other officer continued CPR, although he said the ratio was ten
compressions to one breath. No longer required to assist with CPR, the
night officer went to the gate to help with the emergency access for
paramedics.
132. At about 12.30am, paramedics arrived and were taken to F wing. Once at
the cell, they began carrying out their own checks and setting up their own
emergency equipment. Sadly, they were unable to resuscitate the man
and, at 12.50am, they confirmed that he had died.
Following the man’s death
133. The Co-ordinator told the investigator that following the man’s death, all
prisoners being monitored under the ACCT arrangements were reviewed.
He said this was done to ensure they were supported and to identify
anyone who may have adversely been affected by the death. He went on
to say that notices had been displayed around the prison, explaining what
had happened.
134. I understand from the man’s mother that her family were told of the death
by the prison chaplain, adding that he had been very supportive. She said
the Governor had paid for his funeral and representatives from the prison
had attended.
25
135. I have been pleased to learn from prison staff that they have felt supported
by the Governor and his managers. Members of the local care team made
themselves available to any member of staff affected by the death.
26
ISSUES
Assessment, Care in Custody and Teamwork (ACCT)
136. In October 2008, an ACCT document was opened and remained open until
the man’s death three months later in January 2009. The initial
assessment of his problems is well documented and contains a
comprehensive report for case managers to consider.
137. During the time that the document was open, there were 13 case review
meetings held, all of which the man attended. The ACCT record shows
that there was a multi disciplinary approach to each case review and there
were well documented summaries of the meetings. It is clear from the
records that a great deal of effort went into his care, alternative support
mechanisms were considered and where necessary, action was taken.
138. Despite all the efforts made to keep the man safe, sadly he went on to end
his own life. I am satisfied that the ACCT procedures including the
assessment and case reviews were generally well structured and that he
had every opportunity to engage further with the procedure.
139. One of the expectations is that all case managers are appropriately trained.
In January, although not trained, the SO chaired a case review meeting.
Additionally, although I have not examined this, I understand there are
other managers who have not been trained to case manage, but are
apparently doing so. This, if correct, is contrary to correct procedure. PSO
2700, section 1.3.1 states:
“All Senior Officers, Principal Officers and Operational Managers (F
and above), including Governors and Directors, must be trained to at
least ACCT Case Management level”.
The Governor must ensure that ACCT case managers have received
the necessary case management training and are competent to act as
case managers.
140. I am also concerned about the ACCT monitoring in January. From 8.00pm
on a date in January until the man was found hanging, the ACCT
observations were predictable, in that they were on the hour, every hour.
Whether the man recognised this is not known, but it is possible. Therefore
he would have known that, after the 11.00pm check, he was unlikely to be
disturbed much before midnight. Although I make no criticism of the staff
concerned, I believe the Governor should remind his staff of the need to
vary their observations.
The Governor should remind his staff that ACCT observations should
be varied and not predictable
27
Prisoners requiring constant observation
141. The Co-ordinator said prisoners requiring a level of constant ACCT watch
would be transferred to Exeter, adding that there are no facilities at
Dartmoor. He went on to say that arranging constant observations would
cause operational difficulties, because additional staff would need to be
called in to cover the task.
142. Whilst I make no criticism of the SO, constant watch is not an issue which
should or can be influenced by the need to call extra staff in. Clearly, if
there is a requirement to remain with someone to ensure their safety, then
it should be done without hesitation, and if necessary, less important work
should be stopped.
The Governor should ensure that constant ACCT observations are
provided if they are necessary to ensure a prisoners safety.
Suicide Prevention and Self Harm Management (PSO 2700)
143. During the investigation, it became evident to the investigator that there had
been difficulties at the prison prior to the Governor’s arrival relating to the
implementation of PSO 2700.
144. In April 2009, the investigator met the Area Safer Custody Manager, and
asked him for his views. (He is responsible for coordinating the South West
Area safer custody policy.) He said there had been poor management of
the implementation of the PSO at Dartmoor, along with a lack of
management support. He went on to say that he had raised his concerns
with the area manager in early 2008, who, in turn had asked the then
Governor for an action plan. He said there had been some improvement,
but added there was, at that time, a lack of management support from
some managers at the prison.
145. He said that, since the Governor had taken over, there had been an
improvement and that he (the Area Safer Custody Manager) was content
with the implementation. He stressed there was still more work to do, but
that the changes were being managed effectively by the Governor and
Area Manager.
Safe cells
146. The investigator asked the Area Safer Custody Manager about safe cells at
Dartmoor. He said safe cells form part of the certified normal
accommodation and are meant to be used as normal accommodation. He
added that, although aware that some cells at the prison are referred to as
safe cells, they do not meet the correct specification. He had previously
told the prison managers that they should not be referred to as safe cells.
28
The Governor should satisfy himself that Dartmoor prison staff fully
understand and are able to identify any cells which meet the criteria to
be referred to as either safe, or safer cells. If there are no such cells
at the prison, then this should be made clear to all staff.
Personal issue cut-down tools (anti ligature knives)
147. Although anti ligature knives had been received at the prison in 2008, they
were not issued until the Governor instructed that they should be. The
Area Safer Custody Manager said the failure to issue the knives was part of
the problem with what he said was a “dysfunctional approach” by a
manager at the prison, who was unhappy at applying the mandatory
instructions. I am satisfied that the Governor has resolved the problem and
anti ligature knives have been issued.
148. I have carefully considered the historical problems identified in
implementing PSO 2700. Although I recognise that the current Governor
has given a clear message to ensure the provisions of the PSO are in
place, I am of the opinion that a recommendation would support him.
The Governor should ensure that the mandatory instructions
contained within PSO 2700 are in place.
The night officer
149. Although he had a mouth guard to protect him from coming into direct
contact with the man, the officer felt it was hampering his resuscitation
attempts and, in an act of unselfishness, he discarded it. By doing so, the
officer placed himself at risk of accidentally ingesting body fluid and
potentially causing harm to himself.
150. Prison staff deal with a number of difficult and dangerous individuals and do
not always receive the credit they deserve for doing this difficult job. Sadly,
I have investigated a large number of prison deaths and am often
impressed at the lengths some staff will go to rescue those in their care.
This case highlights another example where an officer placed his own
health at risk in order to do his best for a prisoner. The officer’s actions are
a credit to the service and I believe that his unselfish behaviour should be
commended.
The National Offender Management Service should commend the
officer for his actions in attempting to resuscitate the man.
Clinical care
151. In his clinical review, the clinical reviewer said his recommendations should
not imply criticism of the nurse or the RMN. In his opinion, the nurse acted
in an appropriate way yet found herself in an isolated professional position
without sufficient clear cut support mechanisms. He adds that the RMN
appears to have had the confidence of the man and recorded her views
29
accurately in his medical notes. However, he went on to say that, because
of the way the notes are structured, this important information seems to
have been overlooked subsequently.
152. The clinical reviewer confirms that there is a higher incidence of mental
health problems in the prison population that the general population. A
large number of prisoners will therefore have mental health needs and all
the nursing staff should be equipped to assess these requirements,
especially as they are expected to work in a professionally isolated way and
with a good deal of autonomy. He makes the following recommendation,
which I endorse:
All nursing staff at Dartmoor should receive training in assessing the
mental health of prisoners.
153. The clinical reviewer said it had been difficult to extract the key entries from
the man’s medical notes. He believes the information would be more easily
communicated if a clear summary and risk history was clearly accessible.
He makes the following recommendation which I endorse:
Healthcare should introduce a robust system for documenting key
information which will ensure it can be extracted quickly in
emergency situations by all healthcare staff.
154. The clinical reviewer believes that, once the decision was made to transfer
the man back to Dartmoor, medical staff at Exeter seemed intent on
pursuing this path. This, he adds, was despite the clear opinions from the
psychiatric nurses there that the man was still psychotic and would not
cope with a transfer at that point.
155. Additionally, the clinical reviewer added that the transfer back to Dartmoor
in January, and the initial first few days back at the prison, should have
been better managed. He said there should have been more effort made to
follow up a patient who had been very ill during his stay in the healthcare
unit at Exeter. He makes the following recommendations:
The transfer arrangements between Dartmoor and Exeter must be
much clearer and there should be clear care plans recorded in the
medical notes.
Healthcare plans should, as a minimum, have a summary of progress
while in Exeter healthcare, including the drugs and dosages taken on
discharge and the arrangements for aftercare and follow up.
There should be a contingency plan in place to show what should
happen if the patient’s condition deteriorates. The plan should clearly
note relapse indicators, and when a patient should be returned to
Exeter.
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CONCLUSIONS
156. The man had a number of mental health issues when he went into prison
and which had been identified when he arrived into custody. His medical
record shows that he received a number of mental health interventions and
medication designed to help his symptoms.
157. That said, there is a question mark over the assessments by psychiatric
nurses at Exeter regarding the man’s condition and the healthcare staff
there wanting to transfer him back to Dartmoor. It does appear there was
some disagreement about what was best for him and, in the clinical
reviewer’s view, “intent by healthcare staff to transfer the man back to
Dartmoor”. Additionally, the clinical review shows that the care plan for him
was not clear and, there was no plan in place should he relapse.
158. The man also had a long history of being at risk of suicide and self harm
and had been monitored by the ACCT procedure for several months before
he died. I have considered the ACCT document and am satisfied that
when he first showed signs of harming himself, a file was opened and
remained in place until he died. I am satisfied that the ACCT assessment
was thorough, with regular case reviews taking place, all of which appear to
be well recorded.
159. I am often told that it takes but a few seconds to become unconscious once
a ligature is tightened around the neck and, unless interrupted, the outcome
is usually inevitable. In this case, the ACCT observations on the evening in
January were predictable. Although I cannot be sure, it is entirely possible
that the man came to the conclusion that he would not be disturbed for at
least an hour and acted in the way he did.
160. Clearly, the man had been considered to be at risk for some considerable
time. From what the investigator has read and heard, there were extensive
efforts made to keep him safe. Other than constantly watching someone
deemed at risk, the next best thing is to observe them frequently but
intermittently. However, on this occasion, he was monitored regularly and
hourly.
161. It is clear that the man’s behaviour in January had deteriorated and had
been recognised as such. A great deal of effort went into protecting him
but, oddly, the question of constant watch appears to have been something
which was problematic. In the absence of an urgent transfer to Exeter, I
am of the opinion that constant watch that evening would have been
appropriate. Regrettably, it was not arranged.
162. I am satisfied that there was a quick recognition by the nurse at Dartmoor
that the man’s condition was a cause for concern, and that extensive efforts
were made to transfer him to Exeter. Unfortunately, Exeter was unable to
take him that evening. I agree with the clinical reviewer in that there should
be systems in place to transfer prisoners who are deemed to require full
time medical care to Exeter.
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RECOMMENDATIONS
1. The Governor must ensure that case managers have received the
necessary case management training and are competent to act as case
managers.
The Governor has accepted the recommendation.
2. The Governor should remind his staff that ACCT observations should be
varied and not predictable.
The Governor has accepted the recommendation.
3. The Governor should ensure that constant ACCT observations are provided
if they are necessary to ensure a prisoners safety.
The Governor has accepted the recommendation.
4. The Governor should satisfy himself that Dartmoor prison staff fully
understand and are able to identify any cells which meet the criteria to be
referred to as either safe, or safer cells. If there are no such cells at the
prison, then this should be made clear to all staff.
The Governor has accepted the recommendation.
5. The Governor should ensure that the mandatory instructions contained
within PSO 2700 are in place.
The Governor has accepted the recommendation.
6. The National Offender Management Service should formally commend the
officer for his actions in attempting to resuscitate the man.
The National Offender Management Service has accepted the
recommendation.
7. All nursing staff at Dartmoor should receive training in assessing the mental
health of prisoners.
The recommendation has been accepted.
8. Healthcare should introduce a robust system for documenting key
information which will ensure it can be extracted quickly in emergency
situations by all healthcare staff.
The recommendation has been accepted.
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9. The transfer arrangements between Dartmoor and Exeter must be much
clearer and there should be clear care plans recorded in the medical notes.
The recommendation has not been accepted. The action plan states “Care
plans are already in place in the medical records. Patients are regularly
accepted from other Devon prisons where beds are available”.
10. Healthcare plans should, as a minimum, have a summary of progress while
in Exeter healthcare, including the drugs and dosages on discharge and the
arrangements for the aftercare and follow up.
The recommendation has been accepted.
11. There should be a contingency plan in place to show what should happen if
the patients condition deteriorates. The plan should clearly note relapse
indicators, and when a patient should be returned to Exeter.
The recommendation has been accepted.
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