Individual at Gloucester

Investigation into the circumstances surrounding the
death of a man
at HMP&YOI Gloucester in December 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2010
This is a report of an investigation into the death of a man. The man died,
apparently by his own hand, aged 57 in Gloucester prison. He had been on
remand in the prison for just under a week. I am aware that the nature of the
charge brought against the man was deeply upsetting for all the members of
his family. I would like to offer my condolences to the man’s family and all
those affected by his death.
The man’s death was investigated by one of my senior investigators. One of
the Ombudsman’s family liaison officers was also instructed. The Mental
Health Commissioning Manager from NHS Gloucestershire provided a clinical
review of the man’s healthcare treatment during his time in Gloucester. I am
grateful for his timely report.
I would like to thank the Governor of Gloucester and all of his staff for their co-
operation with this investigation. The man’s death was the first apparently
self-inflicted death to occur at Gloucester for some three years and I am
aware that it impacted greatly on all of the staff. I am especially grateful to
one of the Principal Officers at Gloucester who acted as my senior
investigator’s liaison officer and provided a very high standard of liaison.
I am impressed with the prompt and thorough response of the Governor and
his team to the issues raised by the man’s death. The case was reviewed
and action taken to improve internal systems within hours. I make one
national recommendation concerning the heightened risk of suicide posed by
prisoners who have recently attempted to kill themselves. I also make two
local recommendations and highlight two areas of good practice.
On a less positive note, this case is yet another that demonstrates the
pressure that overcrowding places on local prisons and the potential to put the
lives of prisoners at risk. I believe that Gloucester is overburdened with
vulnerable prisoners and unable to look after all of them in their dedicated
vulnerable prisoner unit. A situation therefore exists whereby vulnerable
adults are located opposite young adults. This is unacceptable for all
concerned. It is difficult to keep both populations safe, and reduces the
opportunity to put vulnerable prisoners in shared cells. In hindsight I conclude
that the man should ideally have been located in the vulnerable prisoner unit
in a shared cell. I have found that the fact that he was not was mostly, but not
wholly, attributable to overcrowding.
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
Acting Prisons and Probation Ombudsman December 2010
2
CONTENTS
Summary
The investigation process
HMP&YOI Gloucester
Key events
Issues
Conclusion
Recommendations
3
SUMMARY
The man was aged 52 years when he died. He suffered from poor physical
health, being a diet controlled diabetic and having mobility issues due to
operations on his knees and feet. On 14 September, 3 December and 11
December 2009 he was reported to have taken overdoses of paracetamol that
required treatment in hospital.
He was arrested on 13 December 2009 and charged with indecently
assaulting his stepson between 1986 and 1990. He was given conditional bail
but was arrested on 19 December for breaching the conditions. While in
police custody, he was diagnosed with depression and prescribed anti-
depressants.
The man was remanded to HMP&YOI Gloucester on 21 December 2009. He
did not arrive with a suicide and self-harm warning form from the police or
court as he should have done. Staff in the prison reception identified him as a
vulnerable prisoner and at risk of self-harm. An Assessment, Care in Custody
and Teamwork (ACCT) booklet (the form used in prison to monitor and
support prisoners thought to be at risk of self-harm) was opened and the man
was referred to the mental health team for an assessment.
The man presented as very low in mood. Throughout the reception and
ACCT assessment process he described his previous overdose attempts as
accidental overdoses of painkillers taken in response to the pain in his knees.
Staff accepted the man’s explanation and did not seek independent
information from outside agencies.
The man was adamant that he wanted to be in a single cell. Staff were not
immediately persuaded that this was a good idea but decided after discussion
to accede to his wish. Overcrowding on the vulnerable prisoner unit meant
that, in order to have a single cell, he was located on the overspill landing
away from the vulnerable prisoner unit and its specialist staff.
Throughout his time in Gloucester the man consistently refused to come out
of his cell for association, showers, medication or meals. He declined the
opportunity to speak with staff. Staff attempted to engage with him and left
meals in his cell. I am critical of the recording and sharing of information
between discipline and healthcare staff.
The man was found dead in his cell at 5.25am on a morning in December
2009. He had hanged himself. Staff went into the cell promptly and
attempted to resuscitate him. The response to finding the man and the care
offered to staff was very good. I identify a training need for regular night staff
to receive emergency first aid training.
I make one national recommendation concerning the heightened risk of
suicide posed by prisoners who have recently attempted to kill themselves. I
also make two local recommendations and highlight two areas of good
practice.
4
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was allocated to one of my
senior investigators on 30 December 2009. As she was on annual
leave, another investigator opened the investigation and collected
relevant documents from HMP Gloucester on 28 December. My senior
investigator contacted the prison on 4 January 2010 and spoke to the
Governor. Later the same day my senior investigator spoke to one of
the Principal Officers at Gloucester and emailed a list of staff to be
interviewed.
2. My senior investigator visited Gloucester on 19 and 20 January and
interviewed eight members of staff. She also visited the wing where the
man lived during his time at Gloucester. My senior investigator spoke
to representatives of the Independent Monitoring Board (IMB) and the
Prison Officers Association. I am grateful to the Chair of the IMB for
providing my senior investigator with a copy of her internal report on the
man’s death. On completion of the interviews, my senior investigator
spoke at length to the Governor and the principal officer at Gloucester.
3. My senior investigator contacted NHS Gloucestershire and spoke to the
Mental Health Commissioning Manager. He agreed to provide a clinical
review of the healthcare received by the man in prison. The report was
received on 16 March 2010, which is within the agreed time limit.
4. One of my family liaison officers wrote to the man’s father, as his listed
next of kin, to explain the purpose of my investigation and offer the
opportunity to raise any issues or questions about his son’s death. The
man’s family have seen a copy of the draft version of this report but
have not made any comment.
5
HMP&YOI GLOUCESTER
5. HMP&YOI Gloucester is a category B adult male prison and young
offender remand centre. It is an old Victorian prison in the centre of
Gloucester and has an operational capacity (maximum overcrowded
capacity) of 323 prisoners. Part of the accommodation dates back to
the eighteenth century.
6. Vulnerable prisoners (VPs) in Gloucester mainly live in a dedicated
unit, with their own staff, on the ground floor of B wing. However, more
often than not, the number of vulnerable prisoners exceeds the number
of places and some are held on B2 landing. This arrangement, while
essentially unavoidable, poses difficulties for both staff and prisoners.
The remainder of B2 is used for young offenders (YOs – aged between
18 and 21 years) and a lot of time and effort is spent ensuring that the
two populations do not mix. Efforts are made to include the vulnerable
prisoners on B2 in the regime on B1 but this is not always possible.
Vulnerable prisoners on B2 are readily identifiable from the ‘VP’ on
their cell cards outside their cell doors. An announced inspection by
Her Majesty’s Chief Inspector of Prisons (HMCIP) in 2007 did not
consider B2 landing a safe environment for vulnerable prisoners.
7. The most recent annual report of the Gloucester Independent
Monitoring Board (December 2008 to November 2009 – the IMB is an
independent voluntary organisation that monitors day to day life in
prison) made the following comments on the situation:
“The Board, while warmly acknowledging the efforts of staff to
mitigate the problems, still has three major concerns about the
treatment of vulnerable prisoners: first, some of them are
routinely accommodated on the same landing as YOs and suffer
both from that proximity and by being separated from other VPs;
second, they experience a less favourable regime; and third,
there are administrative arrangements which make clear to other
prisoners those who are categorised as VPs. The Board
appreciates there may be no easy answers, but that fact does
not make the situation acceptable.”
8. This is the fifth apparently self-inflicted death to occur at Gloucester
since the Ombudsman took over responsibility for investigating deaths
in custody in 2004. The previous four deaths all occurred in 2005. I
draw some parallels between two of these and the man’s case relating
to information being passed into the prison and how staff respond to it.
Suicide prevention and safer custody at Gloucester has received praise
from HMCIP and my investigator was impressed with the initiatives
being taken by the principal officer and his team.
6
ACCT (Assessment, Care in custody and Teamwork)
9. Prisons are run under a series of documents called Prison Service
Orders (or PSOs). PSO 2700 governs procedures for looking after
prisoners at risk of suicide or self harm. Assessment, Care in Custody
and Teamwork (or ACCT) is the system used to identify, monitor and
support prisoners at risk of self harm. The ACCT process is used in all
prisons in England and Wales. Any member of staff can start the
ACCT process by raising a Concern and Keep Safe form, explaining
the reasons for their concern. An Immediate Action Plan is written by
the manager of the wing where the prisoner is located, and within 24
hours an ACCT assessment is carried out by a member of staff who
has the required training.
10. After the ACCT assessment has taken place, a multi-disciplinary ACCT
case review is held to determine what measures can be taken to
monitor and support the prisoner effectively. The prisoner attends the
case review and is encouraged to contribute to the decisions being
made. An ACCT CAREMAP is drawn up with details of each of the
actions necessary to keep the prisoner safe and who is responsible for
carrying out each action. Case reviews are held at regular intervals,
usually monthly, to review the actions and the prisoner’s level of risk.
7
KEY EVENTS
11. On 14 September 2009, the man was reported to have taken an
overdose “that required medical intervention”. He was treated in
hospital and assessed by an approved social worker before being
discharged to his GP. On 3 December, the man was assessed by the
Mental Health Liaison Team in outside hospital having taken an
overdose of paracetamol. The assessment took place in the presence
of two police officers who had arrested him in order to take him to
hospital. The man was de-arrested after the assessment and
discharged from hospital on 6 December.
12. The man was admitted to an Acute Care Unit at outside hospital on 11
December after he took a further overdose of paracetamol. The next
day he was transferred to a police station where, at the behest of the
police, he was interviewed by the senior mental health practitioner from
a crisis resolution home treatment team. He reported that the man’s
mood was low with some evidence of mild depression. He said the
man “was still intent on ending his own life”.
13. On 13 December, the man was charged with indecently assaulting his
stepson between 1986 and 1990. He was given conditional bail, one of
the terms of which was that he have no contact with his stepson or his
daughter. Evidence from the man’s prison record suggests that he
responded to a text message from his daughter with the result that he
was arrested on 19 December for breach of bail and taken to a police
station.
14. A police force medical officer (MO) completed a detainee risk
assessment and care plan the same day. The MO wrote that the man
had undergone surgery to his knees and feet and suffered pain as a
result. He also suffered from arthritis, diabetes (non-insulin dependent)
and depression. His depression had recently been diagnosed and he
had yet to start treatment for it. The MO wrote that the man had taken
an overdose a week previously and had been taken to hospital. He
prescribed citalopram (for depression) and pain relief and anti-
inflammatory medication for the man’s other problems.
15. The next day, on 20 December, police officers asked the MO to
examine the man again because he had not eaten since being taken
into custody. The MO measured the man’s blood sugar and reminded
him of the need to take a regular light diet in order to manage his
diabetes.
16. The man appeared at a Magistrates’ Court the next day and was
remanded into custody and taken to HMP Gloucester. The Clerk of the
Court wrote on the man’s warrant, “NB Defendant has attempted
suicide twice *SUICIDE RISK*”.
8
17. A Person Escort Record (PER) form was completed for the man’s
journey from the police cells to the Magistrates’ Court to HMP
Gloucester. On the risk indicator page “has taken overdose one week
ago” is written in the suicide/self harm risk box. Further down the same
page the risk box for ‘health –mental’ contains the entry, “depression,
previous suicide attempt”. (In these circumstances it is a requirement
that a suicide/self harm warning form should be completed by court
custody staff. The form would then accompany the person to prison
and alert reception staff to a risk.) It does not appear that such a form
was opened on the man during his time at court.
18. On arrival in Reception at HMP Gloucester, a cell sharing risk
assessment form (CSRA) was completed. The first part of the form
was completed by an officer who wrote, “Attempted suicide three
weeks ago. States feels depressed but not suicidal” in the
observations and concerns box. The form was then passed to the
leader of the primary care mental health team and a qualified mental
health nurse (RMN). The leader of the primary care mental health
team completed the medical assessment section and also completed
the man’s first reception health screen.
19. At interview the leader of the primary care mental health team said she
remembered seeing the man’s warrant because it highlighted that he
might be at risk of suicide or self harm. She said the man spoke
abruptly and offered minimal information in his answers. He was
hostile, flat in mood and his appearance was unkempt. The man told
her that his low mood was because of the circumstances he found
himself in. She asked him to talk about the two recent overdoses
highlighted on the warrant. The form indicates that the man said that
the first overdose happened three weeks previously and was a reaction
to “work, health and family” problems. The man told her that the
second overdose had taken place two weeks previously. He said he
had called his daughter who “guessed” what had happened and made
sure he went to hospital. The leader of the primary care mental health
team said she concluded that the overdoses were “cries for help” rather
than determined attempts by the man to end his life.
20. The leader of the primary care mental health team said that the man
denied any intention to harm himself. He said he was fed up but
“wanted his day in court”. At interview the leader of the primary care
mental health team said she thought the man had been at moderate
risk of attempting suicide. She said he had demonstrated some
forward thinking in his desire to be heard in court. Because she
considered that there was some risk that the man would seek to harm
himself she opened an ACCT form (Assessment Care in Custody and
Teamwork – the procedure used in prisons to monitor and support
prisoners thought to be at risk of suicide or self harm). On the concern
and keep safe page at the front of the ACCT, she wrote that she had
opened the ACCT procedures because the man had taken two
9
overdoses in the previous three weeks, presented as very flat in mood
and had said that he was very fed up and felt depressed.
21. The leader of the primary care mental health trust also referred the
man to the doctor for a physical health assessment and to the primary
care mental health team. She did not mark this referral as urgent
because she knew that the man would be assessed as part of the
ACCT process the following day and would also see the doctor. She
wrote a comprehensive summary of her conversation with the man in
his clinical record. She also completed a disability questionnaire with
the man. He described mobility issues due to problems with his knees
and feet. She put on the form that the man should be located “flat”
(meaning that he should be given a cell on the ground floor).
22. The man agreed to accept vulnerable prisoner status because of the
nature of his offence. (Prisoners deemed to be at risk from other
prisoners because of the nature of their offence or other reasons are
categorised as vulnerable prisoners. Vulnerable prisoners are kept
separate from the rest of the prison population). Because of this and
because an ACCT form had been opened, the man was taken to the
vulnerable prisoner unit (VPU) on B1 landing.
23. An officer based on the VPU confirmed at interview that he had spoken
to the man for about an hour on 21 December in his capacity as a
trained ACCT assessor. The officer said he had taken notes at this
meeting. During the meeting the man was adamant that he wanted to
be in a single cell. The officer said he was not immediately persuaded
that this was a good idea. However he discussed it with a senior
officer and they decided that, because the man was so adamant and
because of his age, he should be put in a single cell. There are no
single cells on B1 so accommodating the man’s request on B1 would
have meant moving two prisoners upstairs to B2 (where the overspill
from the VPU are housed). Therefore the man was located in a cell on
B2 landing. The senior officer and the officer who was based on the
VPU agreed that the man’s ACCT should be checked every hour
during the night and that staff should record three conversations with
him during the day.
24. The next morning the officer based on the VPU interviewed the man
again, going through his notes with him, and completing the
assessment interview section of the ACCT form. The man told the
officer that he felt the same as he had done the previous evening. The
officer wrote on the ACCT form that the man said he had taken an
overdose of paracetamol about three weeks previously. The man said
this had been because of his health problems. A week later he had
been charged with indecent assault of his stepson dating back several
years.
25. The man told the officer that he felt low but would not take an overdose
in prison because he would not be able to get hold of enough tablets.
10
He said he did not want to commit suicide because he was denying the
charges against him and he wanted to have the opportunity to appear
in court. The officer was aware that the man was due to appear in
court via videolink the next day on 23 December. At interview the
officer described the man as ‘flat’ and not very talkative. His answers
were monosyllabic and it was not easy to get information from him.
26. Immediately after the officer concluded his interview, he and a senior
officer discussed the man. Together they spoke to him in his cell to
complete the action following assessment review section of the ACCT
document and to agree on a CAREMAP (a care and management
plan). This particular senior officer is not based on the VPU but was
responsible for managing it that day. He has previously managed the
VPU for three years. The senior officer told my investigator that the
man presented as “very flat”. He said he tried to establish what the
man’s needs and concerns were. The man had talked about why he
was in prison and denied that he had done anything wrong. He
repeated that he wanted his “day in court”. The senior officer
described the man as “not disinterested” but said he had not wanted
any help from staff. He asked the man what he would do if he did not
get bail at his hearing the next day. He said the man replied that he did
not know. The senior officer said he had not said this in a despairing
way but rather as if he had not known what the process would be.
27. The senior officer discussed the man’s location on B2 with him. He
was concerned that he would be isolated and wanted him to have the
opportunity to mix with other vulnerable prisoners. He said the man
was adamant that he wanted to be in a single cell and made it clear
that he was not interested in mixing with other prisoners. The senior
officer recorded on the ACCT form that he had told the man that staff
would encourage him to interact and support him if he needed it. The
man had shrugged his shoulders in response.
28. The senior officer said in interview that he was aware that the man had
taken two overdoses in the few weeks previously. He said that the
man had told him that these were accidental and not suicide attempts.
He thought the man appeared “gutted” by his situation. At the end of
the action following assessment section of the ACCT form, the senior
officer and the officer based on the VPU concluded that the man
presented a low risk of attempting to harm himself. The CAREMAP (a
plan of how to manage and reduce a prisoner’s risk of self-harm) was
completed and identified self-isolation as an area of concern. The
officer based on the VPU made an appointment for the man to attend
the safer custody group (a support group for prisoners with open ACCT
forms) to try to mitigate this. A case review was scheduled for 29
December. An entry was written in the wing observation book alerting
wing staff that the man’s attendance at court on 23 December might
represent a trigger for him to harm himself again.
11
29. At 4.00pm the same afternoon, the man attended an appointment with
the doctor. An officer recorded on his ACCT form that she had spoken
to him while he was waiting but that he had not been talkative and
appeared to be in a low mood. A further officer recorded a
conversation at 6.45pm. He said the man had told him his first day had
gone “OK” but he did not initiate any conversation. Later that evening a
nurse gave him his evening medication. She said the man spoke
abruptly to her, asking what she was giving him.
30. The next day, 23 December, when the cells were unlocked the man
declined the opportunity to go to the VPU for a shower and also said he
did not want to choose an evening meal. The officer (signature
illegible) recorded on the ACCT form that the man told him he was not
very hungry and not in a talkative mood. Later the same morning he
was asked if he wanted to attend the safer custody group but he said
he preferred to be on his own. At lunchtime the man attended his bail
hearing via videolink. He was refused bail and remanded until 20
January 2010. In recognition of the entry in the wing observation book
referred to above, a member of staff spoke to the man on his return
from the videolink. The officer (signature illegible) reported that the
man did not want to talk and wanted to be alone. Later that afternoon
the man did not collect his tea meal. He again told staff he was not
hungry and was recorded as not being talkative.
31. On 24 December, the man again said he did not want to go to the VPU
for a shower. Later the same day he said he did not want to leave his
cell for association on the VPU. At 5.45pm he told an officer he was
happy on his own. The next morning, Christmas Day, the man again
refused a shower and told the officer that he was going back to sleep.
He later told an officer that he did not want any lunch. The officer
asked him how he was and he replied that he did not know. The officer
recorded on the ACCT that he had reminded the man of the services
offered by the Samaritans and Listeners (prisoners trained by
Samaritans to provide confidential emotional support to fellow
prisoners in distress).
32. The nurse who had given the man his evening medication on 22
December, remembered giving the man his medication at the treatment
hatch on the mornings of 22, 23, 24 and 25 December. She said he
was supposed to collect more medication from the hatch after the
teatime meal but noticed that he did not. On 25 December, the nurse
asked the man why he did not come down in the afternoons and he
replied, “I will come down if I want it.”
33. The on-going record section of the man’s ACCT shows that, on 26
December, he said he did not want any lunch because he was not
hungry. At 4.00pm he was unlocked for the teatime meal and again
said he was not hungry. A meal was put in his cell but the on-going
record does not show whether the man ate anything. At 5.45pm an
officer tried to speak to the man. The officer wrote in the ACCT that he
12
had asked the man if he would like to talk to a Listener. He wrote, “He
[the man] said he was alright and would I go away”. This is the last
recorded conversation on the man’s ACCT.
34. An Operational Support Grade (OSG) came on duty at about 8.45pm.
He received a handover from the officer who had asked the man if he
would like to talk to a Listener and remembered the officer telling him
that the man had told him to go away earlier in the evening. The OSG
said it is his practice to check all prisoners on ACCT forms as soon as
he has received his handover. The OSG was required to check the
man every hour and record his checks on the ACCT form. He
remembered the man was asleep on his bed on every occasion he
checked him between 8.40pm that evening and 4.40am the following
morning. At about 5.25am the OSG checked the man again and saw
him hanging by a ligature from the window.
35. The OSG said he immediately used his radio to put out an urgent call
for assistance. The control room daily log sheet shows an urgent
message for the night orderly officers to attend B2 landing for a ‘code
blue’ at 5.24am. He then opened his sealed pouch containing a cell
key (OSGs on night duty are not issued with keys for security reasons
but carry a cell key in a sealed pouch for use in emergency.) He was
joined very quickly by the Night Orderly Officer – the officer in charge of
running the prison at night and the only night officer to carry a full set of
keys), and a further two OSGs. The OSG who had discovered the man
hanging opened the cell door and they all entered the cell.
36. The man had used his bedsheet to make a ligature and had tied it to
the cell window bars. Between them the staff supported the man’s
weight and used one of the OSG’s cut down tool to cut through the
ligature. They placed the man on the floor of the cell and the night
orderly officer and one of the OSGs who had arrived with the night
orderly officer in the cell began emergency aid. The night orderly
officer administered rescue breaths and the OSG started chest
compressions.
37. The assistant night orderly officer also responded to the call for
emergency help on B2. He arrived shortly after the night orderly officer
and the OSGs had entered the man’s cell. He took the key from the
night orderly officer and went to the healthcare centre to collect the
emergency response nurse. On the way the nurse collected a bag of
emergency aid equipment from the centre. She felt for the man’s pulse
and checked his breathing. The nurse told my investigator that, in her
opinion, the man was already dead. A further officer arrived in the cell
at this point and he and the nurse took over emergency breaths and
chest compressions and continued until paramedics arrived. The
control room log shows that the paramedics came into the prison at
5.40am. They pronounced the man dead shortly before 6.00am.
13
38. The prison’s death in custody contingency plans were followed and all
relevant persons were informed of the man’s death. A hot debrief was
held the same morning and members of the prison’s care team were
available to offer support to the staff who had found the man.
39. The prison family liaison officer and a senior officer informed the man’s
parents of his death in person later the same day. The prison family
liaison officer visited them again the following day to deliver a personal
letter from the Governor. The prison assisted the man’s family with the
funeral costs and a member of staff attended.
14
ISSUES CONSIDERED
The assessment of the man’s risk
40. Staff in Reception at Gloucester speedily identified from his warrant
and PER that the man presented a risk of suicide or self-harm. The
reason identified on both forms was that he was known to have
attempted to take his own life twice in the community in the previous
few weeks. The leader of the primary care mental health team opened
an ACCT form appropriately and identified the man as a vulnerable
prisoner. She recognised that his mood was flat and that he looked
unkempt. She completed a referral for a mental health assessment.
She said in interview that she did not mark it as urgent because she
knew that the man would be examined by the prison doctor the next
day and that he would be interviewed by trained staff as part of the
ACCT process.
41. I consider that the leader of the primary care mental health team did all
that was required of her during the reception assessment process and
that a referral to the mental health team was certainly required. I note
that a suicide self-harm warning form was not opened on the man in
court and it is therefore to her credit that she properly examined the
documents that travelled with the man and recognised him as at risk.
However, I do not consider that an appointment with the doctor and
assessment by officers as part of the ACCT process was a logical
reason not to mark the referral to the mental health team as urgent.
Neither the doctor nor the ACCT trained officers are mental health
professionals.
42. The question of whether the man would have engaged with the mental
health team is a moot point. His general presentation in Gloucester
would suggest not. I doubt too whether an urgent referral to the mental
health team would have prevented the man’s death. As well, even if
the referral was marked urgent, the holiday period might well have
meant that an appointment could not have been arranged.
Nevertheless, the fact that the man was known to have attempted
suicide in the recent past meant that he presented a heightened risk of
attempting suicide again. I therefore consider that it is good practice
for such prisoners to be urgently referred for a mental health
assessment.
43. One of the officers based on the VPU spoke at length to the man on his
first night. The next morning the same officer and a senior officer
completed the action following assessment and CAREMAP sections of
the ACCT. They spent some considerable time with the man and tried
to obtain as much information from him as possible. They concluded
that he presented a low risk of attempting to harm himself in the future.
44. From their conversations with the man, all three members of staff (the
leader of the primary care mental health team, the officer based on the
15
VPU and the senior officer) were left with the impression, based on
information provided by the man, that his previous suicide attempts
were accidental overdoses of painkillers that he was taking for his
physical health problems. The man told all of them more than once
that he “wanted his day in court”, which they took to mean that he
wanted to move forward and be able to defend himself against the
allegations.
45. Hospital records show that in fact the man had made three attempts to
take his own life since September 2009 and the two most recent had
required hospital treatment and assessment. In outside hospital on 12
December, after the last of his three attempts, the man was reported to
be “still intent on taking his own life”. Reviews undertaken by the
Mental Health Liaison Teams two outside hospitals concluded that the
man presented a high risk of attempting to take his life again.
46. One of the greatest indicators that a person is at risk of taking his or
her own life is if they have attempted to do so in the past. Staff at
Gloucester recognised that the man presented a risk for this reason
and properly opened an ACCT form. However, the information that
they relied on to quantify the man’s risk was confined to his PER, his
warrant and information gained from speaking to the man himself. The
PER and warrant offer bald statements that he had made two previous
attempts to kill himself. Again as noted above, the man himself passed
off his previous attempts as accidental overdoses. He was adamant to
staff that he wished to contest the charges against him in court.
47. Based on the information immediately available to them, I consider that
the leader of the primary care mental health team, the officer based on
the VPU and the senior officer came to a reasonable conclusion about
the level of risk the man posed. However, had they contacted outside
agencies they would have found that the man’s previous attempts were
not accidental overdoses as he claimed. In making their assessment
all three members of staff accepted the man’s version of events.
48. This is an inherently dangerous practice and is an issue that was also
raised in the apparently self-inflicted death of a man in Gloucester in
June 2005. If there is evidence that a person has made a previous
attempt on their life then it is good practice to find out as much detail as
possible from independent sources about the nature of that attempt.
Had the leader of the primary care mental health team and the officer
based on the VPU and the senior officer been privy to the information
possessed by the police and community mental health services about
the nature of the man’s previous attempts to kill himself, then I have no
doubt that they would have evaluated the man’s risk differently. They
might well have decided that he was not in fact suitable to occupy a
single cell on B2.
I recommend that the National Offender Management Service
(NOMS) amend chapter 4 of PSO 2700 (Suicide Prevention and
16
Self-Harm Management) to highlight the heightened risk of suicide
presented by those prisoners who are known to have attempted
suicide recently. Guidance should be offered to staff on how best
to gather information about recent suicide attempts from
hospitals, community mental health teams and other appropriate
sources.
NOMS should consider whether it is appropriate for such
prisoners to have a mandatory assessment from a mental health
professional within seven days of their arrival in prison.
[This recommendation was rejected by NOMS at draft stage. The full
response is reproduced in the Recommendations section at the end of
this report.]
49. Outside agencies also bear a responsibility to pass pertinent
information about a prisoner’s risk to prison staff. I have seen too
many instances since 2004 of important information not finding its way
into the possession of the staff who are required to try to keep
prisoners safe. In this case no suicide/self-harm warning form was
opened at court. The information was available to the court because
the Court Clerk noted the man’s warrant and there was a marker for
self-harm on his PER. The most effective way of alerting a prison to a
prisoner’s risk is via a self-harm warning form. It is not the first time
that information available to the courts has not been passed to the
prison.
50. Paragraph 4.4.2 of Chapter 4 of PSO 2700 states:
“Any difficulties concerning information sharing and Suicide/Self-
Harm Warning Form, ACCT or PER procedures in relation to
contracted escort or police staff should be forwarded to the
Safer Custody Team leader, for discussion at the Safer Custody
Team meeting and follow-up with the contractor and/or the
appropriate PECS Contract Manager or the establishment
Police Liaison Officer.”
51. The Governor and Safer Custody Team leader might wish to decide
whether an approach to the appropriate prisoner escort monitor is
necessary.
The man’s location in a single cell on B2 landing
52. The officer based on the VPU spoke to the man for about an hour on
21 December when he was first taken to the vulnerable prisoner unit.
The man was determined to have a single cell. The officer was not
immediately convinced that this was a good idea and discussed the
situation with a senior officer. After some discussion they decided that,
given the man’s age and his strongly expressed views, he should be
placed in a single cell. All of the cells in the vulnerable prisoner unit on
17
B1 are shared. Staff were faced with a difficult choice. Locating the
man in a single cell on B1 would mean moving two other vulnerable
prisoners from B1 to B2.
53. The next day, as part of the ACCT assessment process, a further
senior officer also discussed the man’s location on B2 with him. The
senior officer was concerned that the man would become isolated if he
was located away from the vulnerable prisoner unit.
54. I consider that both the officer based on the VPU and the senior officer
were right to be concerned about the man’s location in a single cell on
B2. The man appears to have been determined not to interact with
staff or mix with other prisoners. His location on B2 meant that there
was little opportunity of challenging this and also that the man was not
under the direct care of officers dedicated to looking after vulnerable
prisoners.
55. Both the officer based on the VPU and the senior officer told my
investigator that they had reservations about the man’s location on B2.
At the time there were no spaces on B1 and keeping the man there
would have involved at least one other vulnerable prisoner being
moved to B2 in his stead. The pressure on vulnerable prisoner spaces
at Gloucester presents staff with an intolerable balancing act juggling
the various needs of prisoners at risk. With the benefit of hindsight the
appropriate location for the man was probably B1 in a shared cell
regardless of his preferences. At the time and in the context of an
overburdened unit, I can see why he was located on B2 on his own. I
make no recommendation but the Governor will wish to consider the
adequacy of places for vulnerable prisoners.
Assessment, Care in Custody and Teamwork
56. I consider that the man’s ACCT form was completed to a high
standard. The officer based on the VPU and the senior officer sought
to engage with the man and, despite his unwillingness to do so,
managed to complete a thorough assessment. I am especially pleased
to see that, having identified a court appearance by videolink on 23
December as a potential trigger point for self-harm, an entry to that
effect was made in the wing observation book and this in turn prompted
a member of staff to visit the man when he returned to his cell. This is
good practice.
Following up the identification of a trigger point for self-harm by
making an entry in the wing observation book is good practice.
The clinical care given to the man
57. The clinical reviewer’s overall conclusion is that the man received
appropriate care while in Gloucester. However, the clinical reviewer
makes a number of recommendations in his conclusion designed to
18
enhance the level of care provided in the prison. I believe these should
be considered by the Governor and the Head of Healthcare at
Gloucester, in conjunction with the Primary Care Trust.
58. The clinical reviewer’s conclusions reflect my own in that there is room
for some improvement in communication between primary healthcare
staff, primary mental health staff and wing staff and healthcare staff. In
this man’s case, my investigator was told that wing staff were aware
that he was not collecting meals or going for showers and was isolating
himself. They tried to address these issues by putting meals in his cell,
attempting to speak to him regularly and offer him access to support
from the Samaritans and Listeners. However, it does not appear that
healthcare staff were told that he was not eating or maintaining his
personal hygiene. Given that the man was a diet controlled diabetic
and that not eating or washing are common signs of depression this
was extremely useful information for mental health staff to have in their
possession.
59. Similarly, healthcare staff responsible for giving the man his medication
were aware that he did not collect his afternoon medication. The
emergency response nurse told my investigator that she asked the
man about this directly. I can see no evidence that this information
was recorded or passed on to mental health staff or to the prison
doctor. Had all of this information been documented it would have
painted a picture of a man who was staying in his cell, not taking his
medication, not engaging with staff or peers, not keeping himself clean
or eating properly.
60. The clinical reviewer also notes that the man did not have his baseline
clinical observations taken or a secondary health screening or older
man’s assessment in accordance with prison performance health
quality indicator (PPHQI) guidelines.
I recommend that the Governor of Gloucester and the Head of
Healthcare ensure that the recommendations made by the clinical
reviewer are examined and acted upon appropriately. They
should look especially at ways to improve communication
between wing and healthcare staff when prisoners are isolating
themselves and refusing food.
[This recommendation was accepted by HMP Gloucester at draft
stage. The full response is reproduced in the Recommendations
section at the end of this report.]
61. The clinical reviewer highlighted three examples of good practice. I
draw particular attention to the second of them, the prompt case review
commissioned from the Head of Healthcare. She completed her
investigation within 24 hours of the man’s death. Prompt internal
assessments play an important role in learning lessons from such sad
events.
19
The prison’s response to finding the man
62. I consider that the response from staff to finding the man hanging was
very good. They entered his cell promptly and local instructions for
supporting his weight, cutting him down and laying him on the floor
were followed. The night orderly officer began Cardio Pulmonary
Resuscitation (CPR) immediately despite not having a mask as a
barrier to protect her mouth. She deserves credit for doing so. (I
understand that staff at Gloucester have now been issued with masks
with non-return valves.)
63. The emergency response nurse attended the scene as quickly as
possible in the circumstances. She performed the correct number of
compressions to breaths (30:2) according to the latest guidelines from
the Resuscitation Council. I note that the defibrillator was not
automatically brought to the scene. It was not required in this man’s
case as he was quite clearly dead by the time he was discovered.
However, a defibrillator is the only clinically proven method of starting a
non-beating heart. The Governor should therefore consider whether
the local guidance should be amended so that a specific person is
tasked with ensuring that the defibrillator is brought to all code blue
emergencies in the future.
64. All the staff interviewed expressed great satisfaction with the post-
incident care offered by the Care Team and management. However
there was general agreement amongst the staff interviewed that the
local incident report forms are too prescriptive. I am aware that they
have made this known and, for the future, blank forms are to be used.
The hot debrief and critical incident debrief were completed in good
time and staff told my investigator that they found both meetings
helpful.
65. The majority of the staff interviewed who responded to the emergency
and arrived at the man’s cell first expressed a desire for emergency
response training. The night orderly officer had last been trained 23
years previously and one of the OSGs who arrived with the night
orderly officer to the man’s cell had never been trained at all. I
recognise that it is unfeasible and prohibitively expensive for prisons to
ensure that every member of staff has an in date emergency response
qualification. However, given that a significant proportion of prison
deaths occur during the night shift, I consider it prudent for Governors
to prioritise staff who most regularly work at night for training. I
understand that this is already in hand at Gloucester. I make the
following recommendation in support of this:
I recommend that the Governor of Gloucester ensures that staff
who most regularly work during the night shift receive emergency
response training as a priority. This should include senior
20
officers acting as night orderly officers, assistant night orderly
officers and operational support grades (OSGs).
66. The Governor and senior management at Gloucester acted promptly to
analyse the care offered to the man and to look critically at it. A
comprehensive review was undertaken within hours of the man’s
death. The speed with which issues were identified, lessons learned
and new practice put in place is impressive and another example of
good practice.
21
CONCLUSION
67. The man’s death highlights some sadly familiar issues. Once again
there is an example of crucial information not being passed to the
prison from the courts. Again I see an example of the negative impact
of overcrowding on the ability of prison staff to keep prisoners safe. In
this case I am relieved to see that staff at Gloucester recognised the
man’s risk through a combination of paying attention to the documents
that travelled with him and observation and interaction during the
reception screening process. They deserve credit for this. They
deserve credit too for attempting to look after the man and encourage
him to interact. My investigator saw clearly that the man’s death
affected staff at Gloucester deeply.
68. With the benefit of hindsight I believe that more should have been done
to obtain information about the man’s previous suicide attempts. Had
this happened, I have no doubt that it would have affected the
assessment of the man’s risk and his location. Nevertheless, he made
a determined attempt to kill himself when he could be confident that he
would not be found in time for staff to revive him. In cases such as
these it is difficult to think of any practical way in which the death can
be prevented.
69. I am impressed with the prompt commitment demonstrated by the
Governor and his staff to reviewing the man’s case and learning
lessons for the future.
22
RECOMMENDATIONS
National recommendation
1. I recommend that the National Offender Management Service (NOMS)
amend chapter 4 of PSO 2700 (Suicide Prevention and Self-Harm
Management) to highlight the heightened risk of suicide presented by
those prisoners who are known to have attempted suicide recently.
Guidance should be offered to staff on how best to gather information
about recent suicide attempts from hospitals, community mental health
teams and other appropriate sources.
NOMS should consider whether it is appropriate for such prisoners to
have a mandatory assessment from a mental health professional within
seven days of their arrival in prison.
[This recommendation was rejected by NMOS at draft stage. They
responded:
“PSO 2700 Chapter 4 deals with early days in custody risks and
explains that in addition to risk information recorded in the paperwork
accompanying the prisoner, that other sources of information may be
received and used to identify existing or potential risk factors. Chapter
8 explains the response where information is received to indicate that
an individual may be at risk of harm to themselves. Existing policy
adequately covers the increased risks presented by previous
suicide attempts and this information can be obtained either directly
from prisoners or from their records. This is emphasised to all
staff as part of the ACCT Foundation Training and is also
described inside the ACCT document, (page 6 Suicide/Self Harm
Risk Guidance)
“The PER form is the recognised official document for communicating
risk information to and from all relevant parties when a prisoner leaves
and enters custody. Once in custody, the reception screening process
and any subsequent referrals to a doctor or mental health service (if
necessary) are also in place to determine any risks posed. If
necessary, and as part of a consultation, any and all information given
should be followed up.
“As far as the report describes, the establishment and escort
contractor missed several opportunities, (and failed to comply with a
number of policy areas) to identify the heightened risk posed i.e.
(cid:127) a self harm warning form should have been raised by the court
contractor in response to the FME actions and the warning raised
on the warrant
(cid:127) A mental health assessment could have been completed if it
had been marked “urgent”
23
(cid:127) A case review should have been held after his bail decision on
the basis of a change in circumstances.”]
Local recommendations
1. I recommend that the Governor of Gloucester and the Head of
Healthcare ensure that the recommendations made by the clinical
reviewer are examined and acted upon appropriately. They should
look especially at ways to improve communication between wing staff
and healthcare staff when prisoners are self-isolating and refusing
food.
[This recommendation was accepted by HMP Gloucester at draft
stage. The prison responded:
“In liaison with Healthcare, Inreach and kitchen staff the lack of
information sharing has been addressed. A system will be introduced
where these departments will pass on any relevant information to the
orderly officer or Senior Officer in charge of the wing. This information
will have to be recorded as well as any action taken.
“Training will be arranged between Healthcare and DPSM
(Development Prison Service Manager) for prison staff highlighting
changes in behaviour by prisoners for example, lack of personal
hygiene, refusing meals and what action or support is appropriate. “]
2. I recommend that the Governor of Gloucester ensures that staff who
most regularly work during the night shift receive emergency response
training as a priority. This should include senior officers acting as night
orderly officers, assistant night orderly officers and operational support
grades (OSGs).
[This recommendation was accepted by HMP Gloucester at draft
stage. The prison responded:
“Staff will receive local training in emergency response. This was
initiated and will continue. [The] DPSM to liaise with Healthcare. They
have all the facilities to do this training but need to be given allocated
times on training days. [The] DPSM to discuss with HRBP (Human
Resource Business Partner) to make this a priority on training days.
The priority will be SOs, OSGs and B wing staff initially then A and C
wing staff.”]
Good practice
1. Following up the identification of a trigger point for self-harm by making
an entry in the wing observation book is good practice.
2. The Governor and senior management at Gloucester acted promptly to
analyse the care offered to the man and to look critically at it. A
24
comprehensive review was undertaken within hours of the man’s
death. The speed with which issues were identified, lessons learned
and new practice put in place is impressive and an example of good
practice.
25