Individual at Leicester

Investigation into the circumstances surrounding the
death of a man at HMP Leicester in June 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2009
This is the report of an investigation into the death of a man at HMP Leicester in
June 2007. The man was discovered suspended by a bed sheet from his cell
window. Despite efforts to resuscitate him, he did not regain consciousness and was
pronounced dead in his cell. He was 44 years old.
I offer my sincere condolences to man’s family and to all those touched by his
passing.
One of my Family Liaison Officers contacted the man’s family to learn of the
particular concerns they had about his death. I apologise for the delay in producing
this report but I hope that it answers all of their questions.
The investigation was undertaken on my behalf by one of my Senior Investigators.
On behalf of Leicester Primary Care Trust, an independent General Practice
consultant and clinical assessor undertook a clinical review of the healthcare the
man received whilst in custody. I would like to thank the Governor of Leicester and
his staff for their help and co-operation.
The man’s death, ten days after leaving HMP Peterborough, should be seen in the
context of the problems that the prison system faces. He was vulnerable in that he
had a serious mental illness, schizophrenia. He was recalled to Peterborough after
being charged with further offences. He became settled after a month and was
receiving appropriate medication. However, due to a court appearance, he found
himself, unexpectedly, relocated first to a police station then to HMP Leicester under
Operation Safeguard, the system for allocating accommodation to prisoners when
prisons have reached capacity. I regret that Operation Safeguard did not live up to
its name in this man’s case. With the benefit of hindsight, it is clear that the man’s
risk of self-harm was substantially increased by this disruption.
The man had been prescribed medication at Leicester but he had not collected it for
several days. Leicester’s lack of clarity over whether it had done anything about this
further highlights concerns expressed in previous PPO investigation reports about
the quality of Leicester’s healthcare provision.
The report makes nine recommendations which highlight the communication of
healthcare information and accurate completion of Prisoner Escort Records in
particular. The report highlights two areas of good practice.
Jane Webb
Deputy Prisons and Probation Ombudsman September 2009
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CONTENTS
Summary 4
The Investigation Process 6
HMP Leicester 7
HMP Peterborough 8
Key Events 9
Issues 23
Recommendations 30
Good Practice 33
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SUMMARY
In 1999, the man was sentenced to ten years imprisonment for attempted murder
and possession of a firearm with intent. He had been diagnosed with schizophrenia
in 1998. His condition was stabilised with medication. At times whilst he was in
custody, he was severely mentally unwell. In 2003, he was monitored by staff after
saying that he felt like harming himself. A document in his clinical record from 2005
said he had cut himself superficially at least twice and expressed suicidal ideas. He
was released on licence in June 2005 but was recalled to prison six weeks later amid
signs that he was not keeping appointments with medical practitioners and the
probation service. He was released on conditional licence in December 2005. He
was cared for in the community and his mental health was monitored at regular
appointments with his mental health practitioner.
Following new allegations of threats to kill, the man was recalled to prison in April
2007. He was taken to HMP Peterborough where he remained until 22 May when
he attended Peterborough Magistrates Court. The man’s Prisoner Escort Record, a
form which accompanies a prisoner whenever they leave an establishment, was not
endorsed with details of his mental health condition or a request for him to return to
Peterborough. As a result, he was taken to Daventry police station where he spent
the night as there were no places at Peterborough. This was managed through
Operation Safeguard, a system used by the Prison Service, police, courts and escort
contractors, to manage the shortage of prison places by accommodating prisoners
temporarily.
The next day, the man was taken to HMP Leicester. He was referred to the mental
health in-reach team (MHIT) by the reception nurse. A nurse from MHIT did not
contact Peterborough to obtain further information on the man but spoke instead to
the community outreach team who had looked after him before and after his previous
periods in custody.
As part of the reception process, the man underwent a Cell Sharing Risk
Assessment (CSRA) which rated him as low risk. He shared a cell with two different
prisoners in the First Night Centre where he stayed for seven days. Two days after
his arrival, his risk was upgraded to ‘high’ and he was required to be in a single cell
as a result of information received from Peterborough concerning his mental health.
At Leicester the man was prescribed Fluphenazine decanoate, a slow-release
injectable anti-psychotic drug. He was also prescribed Olanzapine, an anti-psychotic
drug but did not collect it for four days. The prescription chart in the man’s clinical
record was marked ‘DNA’ to indicate this. When his allocated nurse saw the man six
days after he arrived in Leicester, however, he told her that he was taking his
medication and he felt well.
The man moved from the First Night Centre to L4 landing on 30 May. He asked an
officer whether he could have a cell mate because he was lonely but the officer
explained that this was not possible due to his high risk level. The man repeated his
request several times over the next two days.
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When he was moved to L4, he had chatted and played table tennis with a prisoner
he had shared a cell with in the First Night Centre. However, the next day, he did
not collect his medication and he returned to his cell early, having told an officer that
he did not like being in a crowd of people. The information that the man disliked
being in a large group of people was in his record but was not known to landing staff.
His cellmate told an officer that the man had sat with his head in his hands and
would not communicate.
On 1 June, an officer spoke to the MHIT nurse just before lunch after noticing that
the man was walking on the spot. The man said he would discuss whether he could
have a cell mate with his MHIT nurse. After lunch, a prison nurse to the man’s cell to
see him and found him suspended by a ligature. The man could not be resuscitated
and was pronounced dead in his cell.
A clinical review was conducted on behalf of Leicester City Primary Care Trust. He
found that the man was possibly in the early stages of a relapse of his schizophrenia.
He made recommendations concerning the coding of medication not being collected
on clinical records, staff protocols for following up uncollected medication and quick
access to essential clinical information on a patient.
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THE INVESTIGATION PROCESS
1. My investigator was given access to the man’s prison records at Leicester and
Peterborough including his medical record, statements from staff and other
documentation.
2. Notices to staff and prisoners announcing the investigation were displayed
around the prison. No responses were received. One of my investigators met
representatives from the Independent Monitoring Board and the local branch
of the Prison Officers’ Association to offer them the opportunity to raise
relevant issues.
3. The man’s family was offered, and accepted, the opportunity to contribute
towards the investigation process. One of my Family Liaison Officers, made
contact with the man’s family. They spoke positively of the kindness and
support they had been shown by Leicester but had several concerns about
the care the man had received at Peterborough in the past. The family
expressed their concern that staff seemed unable to recognise from the man’s
behaviour that he had not been taking his medication. They had made
several telephone calls to Peterborough in the past to find out whether the
man was being prescribed and was taking appropriate medication. They
queried whether healthcare staff were available to prisoners at all times.
4. The family also questioned the suitability of a prison environment for
someone, like the man, with schizophrenia and asked whether prison officers
would have been aware of the man’s condition. They accepted that he had
not given an indication that he was at risk of suicide so he was not subject to
regular checks by staff. Nevertheless, they felt that due to his illness the man
was subject to sudden and unpredictable changes in mood and behaviour
which should have been taken into account. The family felt that the inability of
prison staff to recognise changes in the man’s behaviour was perhaps
indicative of their general lack of understanding of his illness.
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HMP LEICESTER
5. HMP Leicester is a local prison which receives adult men who have been
remanded in custody or sentenced to imprisonment. It is a small city-centre
prison dating from the 19th century which normally holds up to 392 prisoners
mostly in shared cells but, like most local prisons, has experienced
overcrowding. On the day the man died, however, there were 354 prisoners
at Leicester. The main accommodation for prisoners is a four-storey cell
block.
6. Her Majesty’s Chief Inspector of Prisons inspected Leicester in 2003. An
unannounced short follow-up inspection took place in August 2006. Her
second inspection report summarised Leicester’s performance as
“disappointing”, describing it as a microcosm which showed “some of the
problems faced by an overcrowded and stretched prison system”. The report
expressed concern about the operation of the process for supporting
prisoners at risk of self-harm. It also flagged up the deterioration of
healthcare since the previous inspection.
7. The most recent published Independent Monitoring Board report (1 February
2006-31 January 2007) indicated nine areas of concern. This included
concern about the high number of prisoners with mental health issues and the
lack of sufficient staff to offer appropriate support. The report also mentions
the numbers of prisoners arriving late in the evening due to overcrowding at
other establishments, poor representation of staff who should be attending
reviews on prisoners at risk of suicide or self harm and delays in receiving the
results of my investigations.
8. Since PPO took over responsibility in 2004 for investigating all deaths in
prisons, there have been nine apparently self inflicted deaths at Leicester.
The Ombudsman has previously made a number of healthcare-related
recommendations, some of which are relevant to the care the man received in
respect to the issuing and monitoring of medication.
9. At the time of the man’s death, Leicester City Primary Care Trust was
responsible for commissioning healthcare services. Healthcare is divided into
primary and secondary spheres. Primary mental healthcare at Leicester has
been provided since February 2007 by Serco, a private company. Secondary
mental healthcare services are provided by the National Health Service
through the Criminal Justice Team of the local Mental Health Partnership
Trust. The in-reach team consists of two full-time Registered Mental Health
Nurses (RMN) who deal with referrals from the General Practitioner or nursing
staff concerning prisoners who have been diagnosed as having a mental
illness. They do not take direct referrals from prisoners themselves. The
RMNs follow a process known as tracking, to locate the community mental
health service which was looking after the prisoner before they entered
custody, in order to obtain background information. The prisoner who has
been referred is discussed at a weekly multi-disciplinary meeting and
allocated to a particular RMN.
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HMP PETERBOROUGH
10. Until February 2008, healthcare was provided by Peterborough Primary Care
Trust. It is currently provided by Kalyx, the company that operates
Peterborough and several other private sector prisons. Secondary mental
healthcare is provided by Cambridgeshire and Peterborough Mental Health
Partnership NHS Trust.
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KEY EVENTS
The man’s imprisonment:1999 - June 2005
11. The man was sentenced to ten years imprisonment in 1999 for the attempted
murder of his ex-wife’s partner and possession of a firearm. It was his first
period of long-term imprisonment although he had served several shorter
sentences of a few months. He served his sentence in several prisons,
ending up at HMP Peterborough in late 2004.
12. The man’s schizophrenia was managed by medication. His mental health
was maintained by taking 600mg of clopixol by a slow-release injection known
as a depot every two weeks. The man had long periods of relatively good
health but when he stopped taking his medication he would become
psychotic. His illness would take the form of exhibiting delusions that there
was a crystal in his head and coloured sand in his eyes. He would talk about
seeing the devil and his, imagined, Jewish background. Indeed, several
documents in his prison records give his place of birth, erroneously, as
Jerusalem or Israel and describe him as a “foreign national”.
13. Whilst the man’s mental health remained relatively stable, there were
occasions where he gave cause for concern. On 1 June 2003, he told an
officer he had not taken his medication for three days. Houseblock staff
called a member of healthcare staff due to his behaviour. He said he felt like
smashing up his cell and harming himself. An F2052SH booklet was initiated
by an officer. (An F2052SH is a booklet where prisoners at risk of self-harm
or suicide can be monitored and supported. It has since been superseded by
the Assessment Care in Custody and Teamwork process which is a system
that supports and cares for prisoners who are at-risk of self harm or suicide.)
On 9 August, a member of staff wrote in the man’s Record of Events,
expressing concerns about his general behaviour. He had been wearing the
same clothes for two weeks and had noticeable body odour. On 24 October,
the man said that he would take his own life when other prisoners were
asleep.
14. A Local Risk Management Meeting took place in Peterborough on 27 January
2005 to discuss managing the man’s risk on release. This was a multi-agency
panel attended by representatives from the probation service, police, social
services, and mental health practitioners. Parole had been refused in May
2004 due to the man writing letters to his ex-wife (who did not want contact
with him). Whilst the letters did not appear directly threatening, one referred
to “payback time”. The meeting concluded that the man did pose a risk to his
former wife and possibly to himself on release.
15. A psychiatric report was written by a doctor of Suffolk Forensic Psychiatry
Services on 10 March 2005 for the purposes of preparing a care plan for the
man’s release. The plan was for the man to be admitted to a medical centre
in Peterborough General Hospital on the day of his release. This would
provide ongoing psychiatric treatment in a controlled environment and liaison
between the local probation service and mental health team. The man was
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thought to have demonstrated a good degree of insight and compliance
regarding his mental health condition. He had been stable over the previous
12 months and was at low risk of re-offending.
16. On 27 April 2005, the Parole Board granted the man’s application. It
acknowledged that he would require “very close multi-agency supervision”
and a robust release plan. He was released from prison on 27 June 2005 on
parole licence.
In the Community: June 2005 - August 2006
17. The man’s mental healthcare was transferred to the Peterborough Assertive
Outreach Team which looks after clients in the community. A Care
Programme Approach (CPA) report was completed by Cambridgeshire and
Peterborough Mental Health Partnership NHS Trust on 29 November 2005.
(The CPA is aimed at patients with complex mental health needs. There may
be involvement by medical, social work, housing and mental health
professionals. It requires multi-disciplinary assessments and care plans
which are reviewed at regular intervals). The man was described as a
complex individual who required an intensive care approach. It observed that
he had reasonable insight into his illness yet had a tendency to stop
medication with resulting relapses. It noted that when he stopped taking his
medication, he had become psychotically unwell within a fortnight. The
psychosis was characterised by distressing auditory hallucinations which told
him to harm/kill himself. The CPA report said that the man had “cut himself
superficially at least twice while unwell and expressed suicidal ideas.” It
described the man’s early warning signs indicating possible relapse as
increasing pacing, increase in agitation, smirking, pre-occupation, irritability,
impulsivity, attitudinal hostility and wanting to write and send inappropriate
correspondence.
18. The man remained well for several months and complied with taking his
medication and keeping appointments with healthcare and criminal justice
professionals.
19. On 7 June 2006, the man saw a visiting Consultant Psychiatrist. In the man’s
clinical record, his speech was described as bizarre and he stated that he was
an illegal immigrant. On 9 June, the man saw a Community Psychiatric
Nurse. He called her “Babes” and kissed her cheek. She said to him that his
behaviour was unusual but he did not consider it to be so. He appeared
distracted. His clinical record said he was “staring in sinister/intense manner
– denied feeling he could heal with his eyes or was experiencing crystals or
coloured sand in his eyes which are early warning signs for him.” A Care
Programme Approach Co-ordinator was going to contact the man’s sister to
let her know how he was. The man insisted he was Jewish and had arrived in
Britain on a boat with his parents from Jerusalem. The Care Programme
Approach Co-ordinator regarded the man as unwell.
20. The man co-operated with his release plan to monitor his mental health until 1
August 2006 when he did not attend an appointment with his probation officer.
10
21. On 3 August, he was not at home for a scheduled visit from the psychiatric
services and failed to attend a planned appointment with his doctor. As his
mental health was giving cause for concern and he was not available to
receive medication, the decision was taken to recall him as he was not
complying with his licence conditions.
Recall to Peterborough - 4 August 2006 to 22 December 2006
22. The man was recalled to prison on 4 August for failing to comply with the
terms of his release licence. A prison doctor referred him to the in-reach team
the day after his reception. The man was seen by the visiting Consultant
Psychiatrist and an in-reach practitioner. The man’s CPN from the Assertive
Outreach Team visited him on 9 August. He appeared unkempt and pre-
occupied with delusional beliefs. He was taking regular anti-psychotic
medication by mouth and by injection but he was seriously mentally unwell
even so, insisting he was “Jewish”, a sign that his mental health was
deteriorating.
23. The man was moved from healthcare to normal location in Peterborough with
the understanding that, if he felt unwell, he could return to healthcare. He
went to healthcare on 18 August to have his depot injection. The man had
another depot injection on 24 August and stayed in healthcare as his mental
health was in decline. The Consultant Psychiatrist from the Outreach team
visited the man in Peterborough. He told the in-reach team that he had
spoken to a doctor of the Cambridge Forensic Psychiatry Service at
Addenbrooke’s Hospital, looking into the possibility of the man being
transferred to a hospital for treatment. On 31 August, the man was still
insisting he came from Israel.
24. On 1 September 2006, the Parole Board considered the revocation of the
man’s licence. It concluded that recall had been appropriate. The man
admitted missing appointments with his supervising officer and psychiatrist
and not taking his medication.
25. The man moved from healthcare to an ordinary wing on 12 September. He
settled down until 9 October when he went back to healthcare as he did not
feel able to cope on normal location. He was pre-occupied by whether he
would be transferred to a hospital on early release and was not able to
concentrate on anything else. On 20 September, the Consultant Psychiatrist
wrote to doctor at Addenbrooke’s Hospital, asking whether he would be
preparing a Mental Health Assessment for the Parole Board hearing on 20
October. In the event, the Consultant Psychiatrist provided a report for the
hearing recommending release prior to his conditional release date on 22
December, but the matter was not resolved and the man was not admitted to
hospital.
26. On 2 November, the man was admitted to healthcare as he said he was
seeing the devil. This had left him quite distressed. He remained in
healthcare for one month and on 2 December asked if he could go into a ward
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with other patients. He moved into it the next day and appeared happy and
more settled. The man asked to return to his own cell on 18 December. He
was released on conditional release licence on 22 December 2006, which
was the last date he could be kept in custody.
In the community - 22 December 2006 to17 April 2007
27. After the man’s release for the second time, he continued to take his
medication and stayed at the medical centre on a voluntary basis before being
allocated a flat in the community. However, on 13 April, after pacing up and
down the ward for much of the day, the man told the Consultant Psychiatrist
that he felt suicidal and tense in the mornings and was lonely in his flat. He
said he did not want to be admitted so it was agreed that he would attend the
centre during the day over the weekend. The next day, the man arrived at the
centre and asked to stay as an in-patient because he was increasingly being
preoccupied by suicidal thoughts and had planned to hang himself from a
door.
28. On 15 April, the man was arrested outside the centre. He was charged at a
police station in Peterborough on 16 April with the offences of making threats
to kill his ex-girlfriend, on 13 April and possession of a Class C drug
(cannabis). He appeared at Peterborough Magistrates Court on 17 April to
answer these charges and was remanded in custody. A Prisoner Escort
Record (PER) accompanied the man from the police station to the court. A
PER is a written document which highlights risks associated with particular
prisoners. There are three main risk categories – medical, security and other
– with tick boxes for the relevant risk. Under medical, the box “medical
condition” was ticked, along with the security category boxes, “violence” and
“conceals weapon”. Under the section containing further information about
risk, it said “poss of shotgun. Shot male, resist arrest, schizophrenic”.
29. As a result of the further criminal charges, the man was formally recalled to
prison. The reasons for the revocation of his licence were that he breached
condition 5 (i) of his licence in that “you failed to be well behaved, not commit
any offence and not do anything to undermine the purposes of your
supervision, which were to protect the public, prevent you from re-offending
and help you resettle successfully into the community”.
30. During the reception process at Peterborough, Sections 1 and 2 of the Cell
Sharing Risk Assessment (CSRA) were completed by a Prisoner Custody
Officer (PCO). He ticked the form to indicate that he had seen the man’s
Prisoner Escort Record and warrant. The PCO ticked yes to the questions
“Has the prisoner ever abused alcohol or drugs?” He ticked no to the
question “Is there evidence of the prisoner having a previous F2052SH?” (a
self-harm monitoring form). Having used the man’s answers as his source, he
assessed the man’s risk as medium (that there was no immediate risk but the
situation would need to be reviewed regularly) due to his previous convictions.
Section 3 of the CSRA, which gauges whether a prisoner is at risk of harming
others, was completed by a nurse of the Healthcare Team. The box “you feel
that something is wrong” was ticked and the man’s risk was assessed as high.
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In addition the Healthcare nurse wrote that the man would need a single cell.
In section 4, the duty manager decided that the man posed a medium risk but
he should be monitored by wing staff.
31. The man’s First Night Hourly Observation Record said that he seemed calm
and collected. He asked for the observation flap on his cell door to be left
open and this was done.
32. The man was seen by the prison doctor on 18 April. He was prescribed
100mg Fluphenazine decanoate, an anti-psychotic slow release medication
every two weeks. On 19 April, he was seen by a Community Psychiatric
Nurse (CPN) from the mental health in-reach team. After their consultation,
she wrote in his clinical record:
“Seen by in reach he is desperate to work so that he can get off the
wing he does not want to return to healthcare advised that we do not
want him in healthcare and we will support his application to work.
Upset about allegations of threats to kill and that he was in possession
of a gun. He said that he met a woman in a pub and they were
together for six weeks and she fell in love with him and he broke it off
which caused the recall. Compliance with his depot attended
healthcare to have it.”
33. A PCO wrote in the man’s Record of Events on 20 April, “Seems ok on wing
but asking for a job because he feels he will end up back in H/C if he’s behind
his door all day.”
34. On 23 April, the man saw a nursing Sister in the healthcare centre. He asked
for a letter he could give to his wing officer to allow him to get some work as
he was becoming distressed without anything to do. The nursing Sister
provided the man with the letter. On the same day, the Post Release Section
of the Public Protection Unit faxed Peterborough a copy of the man’s licence
revocation order. It included the message “Please note that it has been
brought to our attention that the man shows issues of vulnerability in custody
in that: he has Mental Health issues in last sentence and will struggle with
recall.”
35. The man appeared at Peterborough Magistrates Court on 24 April, and was
remanded in custody until 22 May. He signed a Confirmation of Disclosure of
Recall Dossier/ Representations Against Recall form. He indicated that he
wanted to make written representations against his recall through his legal
representatives.
36. The man was moved to healthcare on 28 April as he had begun to feel fragile.
An entry in his Record of Events (signature illegible) read “Seems ok but
would like to double up because he is lonely.” On the same date, a PCO
wrote, “Admitted to H/care – explained to him that I am his personal officer.”
37. On 30 April, the man had an appointment with his CPN. He told her his
medication was giving him cramp and he wanted to remain in healthcare
13
because he could not cope on the wing. He also said he was seeing the devil
on the wing. He was admitted to healthcare. On 4 May, he expressed the
view to his CPN that he should be associating with other prisoners. It was
agreed that he could return to wing once he had been seen by a doctor.
When the man reported the same delusion to his CPN again on 8 May, she
reassured him that he would not have to return to his wing. He remained in
healthcare until 14 May.
38. On 5 May, the man made an application to be transferred to HMP Guys
Marsh. His application read in part “I am a paranoid schizophrenic, the devil
is in this prison plus Bullingdon and Grendon prisons … I would like to settle
into one prison and be rehabilitated. Guys Marsh can sort me out.”
39. The PCO wrote in the man’s Record of Events booklet on 5 May that his
television was removed from his cell for his own safety after he threatened to
smash it. The next day the PCO made an entry in the Record of Events that
the man kept saying the devil was in the prison and he wanted to be
transferred. The PCO asked a nurse to contact in-reach to see the man.
40. The man was seen by his CPN on 7 May. She noted in his clinical record that
he was very agitated, saying that the devil was on the wing. The man was
reassured that he could stay in healthcare and he would not be moved back
to the wing unless he wanted to. He received a reply dated 8 May from
Peterborough’s Observation, Classification and Allocation (OCA) unit that
arranges transfers, “Unfortunately we do not allocate to Guys Marsh.”
41. On 10 May, a Public Protection Panel meeting to consider the man’s risk
management took place. The names of the participants are not recorded.
The meeting considered input from different areas of the prison and heard
that the man had asked for a job. The man feared he would end up back in
healthcare if he was locked in a cell all day (which had occurred) and he had
asked to share a cell with another prisoner.
42. The man’s probation officer commented that he was being managed well in
healthcare but did not do so well when moved to a houseblock. Mental health
in-reach said that the man came across as vulnerable and did not like large
groups of people. The security department’s contribution was that the alleged
victim of the offence for which the man was recalled and remanded in custody
was retracting her statement.
43. A PCO wrote in the Record of Events booklet on 10 May that the man said he
was surrounded by the devil and had x-ray vision. He was pacing up and
down and said it was all he could do when he was on a high.
44. On 12 May, a Cell Sharing Risk Review took place and a document with its
findings was completed. It gave the man’s current risk rating as medium. It
mentioned his previous conviction of attempted murder. Under the question
“Has the prisoner displayed any anti-social behaviour, bullying, threats,
damage to property, aggression, hate-motivated behaviour, assaults?” The
response read “Current offence threats to kill made threats to kill others April
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07 because devil told him so + markers for possession of shot gun + resisting
arrest.”
45. In response to other questions on the form, it was noted that the man was
suspected of using cannabis. The security department did not have any
information which would affect the risk assessment. The question about
whether there was a history of self-harm was not answered. The PCO wrote
that healthcare information was that the man was known to the In-reach team
as he said he saw the devil in his cell telling him to harm others. He was
possibly a sufferer of drug-induced psychosis and staff should treat him with
extreme caution due to his history of violence and current mental state.
46. The man met with his CPN on 14 May. They talked about the last time they
had met on 11 May and how unsettled he had been. The man admitted that
he had been feeling under stress but he believed he was now ready to try
going back to normal location. After the meeting, his CPN discussed the
man’s possible move back with a doctor and officers on the houseblock to
which he would return. It was agreed that he could be discharged from
healthcare with the understanding that if he deteriorated, he could return
there.
47. On 22 May, the man left Peterborough for a court appearance at
Peterborough Magistrates Court. His CPN was on annual leave. The man’s
core record had been signed to say that he was fit to attend court. However,
there was no record on System 1, the internal healthcare computer tracking
system, to show that he had been fitted for court. He was accompanied by
Prisoner Escort Record (PER) which is used to highlight any information of
special importance about the prisoner being escorted.
48. Operation Safeguard is a system which came into operation in October 2006
and is used by the Prison Service, police, courts and escort contractors to
manage the shortage of prison places for persons remanded in custody. It
matches the availability of spaces with the demand and makes provision to
accommodate 400 prisoners in designated police stations and court cells until
prison spaces are available. In the event that prisons are unable to accept
more prisoners because they are full, Operation Safeguard has a protocol
which sets out which prisoners will be given priority for a prison place. These
include young offenders, women, category A prisoners, those actively at risk
of self harm or suicide and prisoners who have significant healthcare issues.
In order for escort staff to be aware which prisoners fall into these categories
if not apparent, Prison Service Instruction (PSI) 30/2006 states that their “PER
forms must be endorsed ‘RETURN TO DISCHARGING ESTABLISHMENT.’”
49. On the man’s PER, the risk categories section of Part A was completed by a
PCO on 21 May. The man’s PER was not endorsed according to the PSI.
Under “medical”, the boxes for medical or mental condition were left blank and
the box for “no known risk” was ticked. Under security, the boxes for violence
and “conceals weapons” were ticked. Under “other”, the box for drugs/alcohol
issues was ticked. In the section “further information about risk”, the PCO
wrote “violence, threats to kill. Drug offences. Weapons, shotgun”. The man
15
was remanded in custody to appear at Peterborough Crown Court on 22
June. Part B of the PER is a record of events. It shows that the man left
Peterborough at 7.55am and arrived at court at 8.10am. He left court at
2.25pm and was taken to Daventry police station, arriving at 3.45pm. He
spent the night there and was handed over to the escort contractors the next
day at 12.35pm, arriving at HMP Leicester on 23 May at 1.35pm.
50. At Leicester, the man was seen on reception by an officer. The officer
completed section 1 and 2 of a CSRA using information from the man’s PER,
court warrant and his answers to the set questions put to him. The officer did
not have the man’s medical record. The man’s risk was assessed as low.
The reception officer described him as polite and co-operative. The
healthcare section of the CSRA was completed by a nurse assessed the man
as low risk. In the man’s clinical record on the form ‘Further Reception Health
Checks’, under the ‘Change in Circumstances’ heading, the nurse wrote
‘Rec[eived] HMP Peterborough’.
51. The man was taken to the First Night Centre for prisoners new to Leicester,
which was located on the ground floor of the residential accommodation
block. An officer interviewed the man in the First Night Centre. His low CSRA
was noted and he was given £2.00 telephone credit, an envelope, writing
paper and a visiting order. He was asked to read and sign several compacts
concerning Leicester’s policies, rules and routines. The man was given a free
telephone call to his sister at 6.35pm to let her know he was in Leicester.
They talked about arranging for her to visit. He was given cell L1-26 which he
shared with another prisoner.
52. The next day, the man started the induction process. The facilities of the
prison were explained and he was told how to access particular services such
as arranging visits and having money sent in. The first night induction
checklist gives a number of subjects that should be covered. None of them
are ticked, however, and the signature of the officer who completed the form
is illegible. The man remained in the same cell but was allocated a different
cell mate.
53. The mental health in-reach team (MHIT) nurse wrote in the man’s clinical
record on 24 May that he was on an enhanced CPA with a diagnosis of
schizophrenia. She had contacted the Assertive Outreach Team in
Peterborough after receiving a referral from the nurse working in Reception
who saw the man on his arrival. My investigator has been unable to find
documentation detailing how the Reception nurse became aware that the man
had mental health issues. The Reception nurse left Leicester in August 2007
and now works at HMP Gartree. My investigator interviewed her by telephone
in October 2008. She said that she did not have a strong recollection of the
circumstances of the man’s arrival at Leicester or what he said to her that day.
However, she did remember him having a distinctive face and eyes. She
thought that she might have gleaned information about the man from his
clinical record and made a referral to MHIT on that basis. The man’s
prescription chart in his clinical record showed that he had been prescribed
15mg of Olanzapine daily for 28 days.
16
54. On 25 May, Leicester’s parole clerk was sent documentation concerning the
Parole Board’s review of the man’s case three days earlier. The Parole Board
concluded that his recall had been justified and a further review was
scheduled for 22 November 2007. It indicated that the man’s case would be
reconsidered in the light of the outcome of his outstanding court cases, his
progress whilst in custody, his psychiatric assessment and any proposed risk
management plan to manage his mental health in the community. There is no
indication, however, that the man was aware of his review date.
55. The man’s cell sharing risk was reviewed on 25 May by a Senior Officer (SO).
The man’s risk was raised to high after information received from
Peterborough suggested a history of mental health issues. The SO amended
the CSRA completed on 23 May to reflect her concerns. As the SO has been
on long-term sick leave, my investigator has not been able to interview her.
56. According to his Record of Events, the man was asked to complete his
education induction but refused to attend. Disciplinary action was taken
against him in the form of a “strike” or a written warning about his conduct.
57. The man’s Medication Administration Record Chart in his clinical record
indicates he did not collect his anti-psychotic medication, Olanzapine, on 26,
27 and 29 May and 1 June.
58. On 29 May, the MHIT nurse spoke to the man briefly at his cell door to
introduce herself and find out whether he had any acute worries or concerns.
She told my investigator that the man came across as pleasant and, apart
from his “very stary eyes,” appeared relaxed. She asked him if he was fine
with his medication and he replied that he felt well and was taking his
medication. She told him that he should ask for her if he needed to but she
would arrange to see him more privately in Healthcare. The MHIT nurse
wrote in the man’s clinical record that she would see him again for a full
interview. She described to the investigator the difficulties in securing a
satisfactory interview room. The rooms in the First Night Centre were poorly
designed and too small while the only interview room in the Healthcare centre
was in constant demand and had to be pre-booked. The date of that interview
was not specified.
59. In answer to my investigator’s questions, the MHIT nurse said that she would
not normally see a prisoner until she had digested their background
information. She said that she could not remember whether she had actually
contacted Peterborough in-reach team, but thought it was possible she did
because there was extensive information about the man in his clinical record.
She was asked whether in-reach at Leicester would follow up what happened
to a patient if they did not return from court. The MHIT nurse replied that she
would check on the computer system to see where they were. If it was
unclear, she would ask the custody office, which manages prisoners’ records,
to check a national database and, failing that, she would contact the court
which the prisoner had attended.
17
60. The MHIT nurse was not sure whether Peterborough’s in-reach team had
contacted her to confirm the man’s whereabouts. Her feeling was that his
stay at Leicester would have been brief given that he was due to appear in
court in Peterborough. The investigator acknowledged that in MHIT nurse’s
role as a mental health nurse, she would not have expert knowledge of the
prison service’s arrangements for transferring prisoners. Asked whose
responsibility she thought it would be to trace a prisoner and arrange for them
to return to their original prison, she felt that both the sending and the
receiving prison had equal responsibility. She added that she had contacted
the Offender Management Unit at Leicester to find out whether the man was
likely to remain in Leicester but his position was unclear.
61. The man’s induction documentation was updated on 30 May when he was
given four sentence planning targets to aim towards. They were to work with
wing and healthcare staff towards sharing a cell, attend education or gain
employment, engage with the personal officer scheme and work towards
enhanced Incentives and Earned Privileges Scheme status. The form has a
section to be completed by the man’s personal officer but it was not
completed, nor was the personal officer identified. An officer told my
investigator subsequently who the man’s personal officer was. The staffing
roster showed that this officer was on annual leave when the man was
allocated to her.
62. On 30 May, the man was moved from the First Night Centre to the landing for
convicted prisoners. He was given cell L4-03 and his CSRA history sheet
was marked to indicate that he was to be in a single cell. He did not collect
his medication that day.
63. An officer wrote in a typed note after the man’s death that the man had rung
his cell bell several times on 30 May. The officer answered and the man
asked him if it would be possible for him to have a cell mate because he
wanted a companion in his cell. The officer discussed the man’s request with
a Senior Officer. On looking in the man’s personal file, he noted the high risk
CSRA, and the comments about assault on it. The officer saw that the man
had not been given personal officer information or landing rules and
information. The officer then went with a colleague to the man’s cell, told him
who his personal officer was and asked how he was feeling. The man said he
wanted a cell mate because he was starting to feel funny. The officer said to
the man that he would not be able to have a cell mate until his next CSRA
review on 26 June. He asked the man if he knew why he was high risk and
he said it was because he was a paranoid schizophrenic. As he talked to the
officer the man began walking on the spot. As the officers left the cell, the
man asked whether the observation flap in the cell door could be left open so
that he could at least see other people. The officers agreed to this. The
officer made a note of his conversation with the man in the wing observation
book and discussed it with the SO who said that they should monitor him for
the rest of the day.
64. The man made three telephone calls on 31 May at 7.55am, 9.03am and
9.06am which were retrieved from the telephone system (after his death) and
18
transcribed. His first call was a brief one to his sister, asking her to telephone
his solicitor concerning how long he would have to serve now that he had
been recalled from licence. The second call was to his former girlfriend. They
discussed a statement she had made to the police but later withdrew, about
the man’s conduct, which had led to him being recalled. The man telephoned
his sister again. He asked when she would be visiting him. On being told that
she had tried but had been unable to book a visit, he said that she should wait
to see the outcome of his court case in June before visiting. He asked
whether she had redecorated his bedroom (he was due to live with her on his
release) and after some affectionate chit-chat, they finished the call. The
same day, the man was given another warning by for “constant misuse of cell
bell.” My investigator wrote to the officer who issued the warning asking him
to provide more detail on the circumstances around the warning. Part of his
reply said “in the case of the man misusing his cell bell system, he had not
had any previous warnings so I thought it was best to inform him that he had
broken a landing rule by reading to him and then issuing him with the written
warning slip.”
65. The mans prescription chart showed that he was prescribed 100 mg
Fluphenazine decanoate, although his clinical record does not indicate
whether it was actually administered.
66. The prisoner who was in cell L4-05, next door but one to the man and who
had shared a cell with him in the First Night Centre, told an officer after his
death that the man usually played table tennis with him and his cell mate.
However, on the evening of 31 May, the man sat with his head in his hands
and would not communicate. At interview, an officer told my investigator that
the man had returned to his landing early from association. The man had said
that he was not comfortable in the association room as there were a lot of
people and he did not like being in a crowd.
67. The next morning, 1 June, the man did not collect his medication. He went
out on the exercise yard with other prisoners. An officer told my investigator
that this had surprised him, given that the man had returned to his cell early
the previous evening after saying that there were many people in the
association room. During the exercise period however, the man walked
around the exercise yard with his head down, kicking the ground and would
not speak to his cellmates. They assumed he wanted time on his own so they
did not mention his behaviour to an officer. My investigator asked one of the
men about the man’s behaviour but he could not recall the encounter. He
said that his cellmate was the one who used to speak to the man. The cell
mate has been released from Leicester and, unfortunately, could not be
contacted.
68. At lunch time on 1 June, an officer noticed the man walking towards him. The
officer asked the man if he was okay as his eyes were “wide open like a rabbit
caught in car head lights”. The man replied that he was but just as the officer
was about to shut his cell door, the man asked again if he could have a cell
mate soon because he felt lonely. The officer commented to my investigator
“he was just lonely … just kept telling me he was lonely all the time”. The
19
officer repeated that he would have to wait for a review to take place. The
man then said that he would be seeing some one from the mental health in-
reach team in the afternoon so he would mention wanting a cell mate to them.
The officer agreed that this was a good idea.
69. After shutting the man’s cell door, the officer approached a nurse from the in-
reach team who was walking up the landing, and asked her if she knew the
man. The nurse replied that he was her colleague’s patient. The officer said
to her that the man was asking to see someone from in-reach especially
concerning being able to share a cell. The nurse said she would pass what
the officer had said to her colleague.
70. The officer went back to the man’s cell to let him know that someone from in-
reach would be seeing him. The man asked whether it would be that day. He
thanked the officer, asked for his observation flap to be left open and
continued to eat his lunch. The officer told my investigator that it was not his
usual practice to leave an observation flap open but he felt the man’s request
came across as genuine. The man had said to him that if he did not have a
cell mate, it would help if he could see other people going past his cell. About
ten minutes later, another officer who was standing outside the man’s cell,
shouted across the landing to his colleague that the man was asking about
seeing a member of the outreach team in the afternoon. The first officer said
that he had already dealt with the matter and someone from the in-reach (not
the outreach) team would hopefully meet the man that afternoon. The second
officer relayed this to the man. The second officer said to my investigator that
he was aware the man had been recalled on licence but even though he
regularly encountered such prisoners, he did not know much about what it
entailed.
71. At interview, the man’s allocated in-reach team nurse said she did not
normally work in the prison on a Friday but, unusually, she went to Leicester
that day as she had some spare time. Just before midday, her colleague told
her that the man wanted to see her but, as he was already locked in his cell,
she decided to see him after lunch.
The discovery of the man’s death and aftermath
72. After lunch on 1 June at about 2.00pm, the nurse told an officer who was in
the staff office on L4, that she was on her way to speak to the man in his cell.
Although an officer had left the flap covering the man’s cell door observation
panel open before he went off duty at lunchtime, the nurse told my
investigator that when she reached the cell, the flap had been closed. She
opened it, looked into his cell through the observation panel and saw him
suspended from the window bars by a strip torn from a bed sheet. She
unlocked his cell and went in, then touched him. She told my investigator that
he was “not stone cold but pretty cool to the touch”. She said she was not
carrying a radio or a ligature-cutting tool as these are not issued to non-
uniformed staff.
20
73. The nurse went to the cell door and shouted for staff assistance. However,
she said that the wing was noisy and she was not sure whether she had made
herself heard but she went back into the cell and tried to lift the man but he
was too heavy so she came out of the cell and shouted for staff again. She
said that officers probably arrived in less than a minute from the time she first
raised the alarm.
74. An officer responded and ran to the man’s cell, along with another officer
This officer handed his ligature-cutting tool to the first officer who cut the
ligature around the man’s neck. The officer said the man was placed on the
floor but he was very cold and he could not find a pulse.
75. The same officer began cardio-pulmonary resuscitation (CPR) until other
healthcare staff arrived. Resuscitation was attempted by two officer’s . A
nurse arrived at the man’s cell with an emergency response bag in response
to a radio message for urgent attendance from a healthcare member of staff.
Two further nurses also arrived. The man did not regain consciousness. An
ambulance was called at 2.03pm and arrived at the prison at 2.06pm.
76. Leicester’s General Practitioner arrived at the man’s cell at 2.10pm. He could
not detect a pulse or a heartbeat. The man’s pupils were fixed and dilated
and the General Practitioner pronounced his death at 2.20pm.
77. A hot debrief was held after the necessary administrative procedures following
the man’s death had been completed. The purpose of the debrief was to
bring together all staff who had been involved in the immediate aftermath of
finding the man. The hot debrief was chaired by the Deputy Governor, and
was attended by all relevant staff and representatives of the Staff Care Team.
It enabled the staff present to discuss how the man’s death had been handled
and air any issues that had arisen as a result.
78. After attending the hot debrief, Leicester’s Prison Chaplain, and a Principal
Officer left Leicester at 4.50pm to drive to London in order to break the news
of the man’s death to his family. They arrived at the family home at
approximately 8.30pm.
79. The man’s sister was very distressed at the news of his death. She told
Leicester’s FLO that her brother had telephoned her and did not give any
indication that he intended to take his life. In fact after she had last spoken to
him, she had telephoned her aunt to say that he sounded really well. Her
brother had told her not to visit him at Leicester but to wait until his next court
appearance as he believed he would return to Peterborough prison. She had
agreed to do this. The man’s family were grateful that staff had travelled from
Leicester to London to tell them of the man’s death in person.
80. The man’s family were offered and accepted the opportunity to visit Leicester
to meet prisoners and staff who had cared for him. His family were touched
by the generosity of prisoners who organised a collection and raised £195.
They were all the more appreciative of this mark of respect for the man’s
memory, given that he had only been at Leicester for a short time.
21
81. My investigator spoke to a member of the mental health in-reach team at
Peterborough who had known the man during his time there. She said that
after the man went to court on 22 May, she did not realise that he was in
Leicester until she was told about his death, four days after it occurred. She
added that the man was well-known at Peterborough and, if the in-reach team
at Leicester had contacted her, she would have been happy to try to negotiate
a return to Peterborough for him. She was mystified as to why Leicester in-
reach had not contacted their Peterborough counterparts.
82. A post mortem examination was conducted on 5 June by a Forensic
Pathologist. His report described the man’s cause of death as hanging.
Samples of the man’s blood and urine were analysed for the presence of
medicines, drugs and alcohol. My investigator discussed toxicology tests with
a member of the forensic pathology team which analysed the man’s samples.
She asked whether the toxicology report would indicate if the man had
actually taken the medication had been prescribed. He replied that, although
no identifiable drugs (illegal or prescribed) had been found specific tests to
identify particular medication might not have been carried out. This meant it
was possible that medication was present in the man’s body but did not
register.
83. An operational review into the dispensing of psychotropic medicines in the
Healthcare department at Leicester was conducted by Serco’s Senior
Investigations Officer. The report of his findings detailed that the man did not
collect his medication on 26 and 27 May. The man was seen by a prison
nurse on 28 May and advised to collect his medication. The nurse then
referred the matter to the in-reach team and the man was seen by his
personal nurse on 29 May. The report found that “although on interview the
staff of the HCC stated that they do inform ‘In Reach’ when they have
concerns with regards to a patient of his treatment … there is however a
universal apathy to the recording of such information on Prescription Charts
and IMRs and there is no managerial input or checks and balances and as a
result there is no ‘Audit Trail’.” The Senior Investigations Officer concluded
that although the fact that a prisoner did not appear is noted, it is left to
individual nurses to follow up. He recommended that there should be
managerial oversight of prescription charts and the whiteboard which is used
for the recording of the dispensing of psychotropic drugs. My investigator was
unable to discuss the SERCO report with the prison nurse due to the nurse’s
sick absence.
84. After the man’s death, Leicester’s Healthcare Manager issued a Notice to
Staff on 4 June which read:
“All qualified staff are reminded that it is their responsibility to
investigate why someone prescribed anti-psychotic medication is not
attending for their prescribed medication, simply documenting the fact
that the patient has not attended is not sufficient. When you have
discovered the reason behind the non-attendance this must be
documented in the patient’s medical record.”
22
ISSUES
85. The man battled with schizophrenia for most of his adult life. He responded to
treatment both in the institutional settings of hospital and prison and in the
community. His risk to the public or particular individuals was managed in a
multi-disciplinary setting by professionals who showed an in-depth
understanding of his behaviour assisted by valuable input from his sister, who
had maintained a close and supportive relationship with him throughout his
years of imprisonment.
86. The man’s condition was stabilised by a mixture of slow-release injections and
daily oral medication and regular review under a recognised Care Programme
Approach with skilled mental health practitioners. The man was vulnerable
however, when he stopped taking his medication as his psychotic symptoms
would return. Whilst serving his sentence, he rarely gave cause for concern
that he would harm himself. On one occasion, in June 2003, an F2052SH self
harm monitoring form was opened after he displayed disturbing behaviour and
told staff he felt like smashing his cell and harming himself. Four months
later, the man said he would take his life when other prisoners were asleep.
The CPA report dated 29 November 2005 referred to the man cutting himself
superficially on at least two occasions and expressing suicidal ideas. It is
unclear, however, whether those events were historical or whether they took
place in custody. Apart from these episodes, there is little documentary
evidence that the man had expressed suicidal intent until he told the
Consultant Psychiatrist on 13 April 2007 (shortly before being arrested) that
he was preoccupied by suicidal thoughts and planned to hang himself from a
door.
87. The man was recalled to prison on two occasions under the provisions of the
Criminal Justice Act 2003 which, under Prison Service Order 6000, sets out
conditions for the early release and recall of prisoners. The first time his
licence was revoked was on 4 August 2006, 14 months after release on
parole when he was not co-operating with the psychiatric services. He was
released three months later on licence as he had served the full required
period in custody.
88. After being arrested, charged with a serious offence and remanded in
custody, it was perhaps inevitable that the man would have been recalled to
prison. Given the nature of the original offence that he had been convicted of,
allegations that he had committed an offence which had similar hallmarks had
to be taken seriously.
89. When the man was taken into custody in April 2007, the Prisoner Escort
Record that accompanied him from the police station to court on 17 April,
contained information that he was schizophrenic. Despite his family’s
concerns about the care he had previously received at Peterborough, his
mental health condition seems to have been acknowledged and appropriately
handled. It was reasonable that an Assessment Care in Custody and
Teamwork (ACCT) document was not opened at that point. The man was
23
allowed to have the observation panel flap open when he asked and he saw a
doctor within 24 hours of his arrival. Medication was prescribed promptly and
he was referred to and seen by the in-reach team.
90. However, in contrast to his previous period in custody, the man appears to
have been anxious about being locked in a cell by himself without a job. He is
variously described in his clinical record and Record of Events as desperate
to work, upset, distressed, lonely and agitated. The Post Release Section of
the Public Protection Unit drew Peterborough’s attention to the man’s
vulnerability due to mental health problems and correctly predicted that he
would struggle with recall to prison. The man talked on several occasions of
the devil being in the prison and gradually he exhibited more of the trigger
signs that his psychosis might be returning. He told staff he was surrounded
by the devil, he was seen to be pacing up and down and he said he had x-ray
vision.
91. At the time when the man attended court on 22 May, concern that prisons
were unable to accommodate the number of people being sent to them was,
as now, a pressing issue. Operation Safeguard was devised to co-ordinate
where and how available spaces would be filled. In practice, it meant that in
the quest to meet demand, prisoners could and were sometimes being
located at short notice in prisons far from their homes.
92. Although the man’s core record was signed on 21 May to say that he was fit
to attend court, a lack of co-ordination meant that this was not recorded on
System 1, Peterborough’s healthcare tracking system. This meant that
although the in-reach team should have been aware that the man had left
Peterborough and was attending court, they were not. This was a mistake.
The man was suffering from a serious and enduring mental illness, albeit
under control. It was essential they knew of his whereabouts so that
adequate follow up could be undertaken if he did not return.
I recommend that Peterborough devises a system to ensure that
prisoners who attend court or leave the establishment are recorded on
System 1.
I recommend that the Director of Peterborough reminds staff that
signatures on documentation must be legible.
93. The question as to whether the man’s PER should have been endorsed for
him to return to Peterborough is a finely balanced one. With hindsight, it
would have been desirable for him to return. Nevertheless, it might have
been more acceptable for Peterborough not to endorse the PER provided that
it showed all relevant information about the man. Clearly it did not. It was the
failure to provide sufficient relevant detail about the man’s mental health
history combined with the absence of a request for him to return to
Peterborough that left him vulnerable.
94. Peterborough did not have a specific system for requesting that prisoners who
might be vulnerable due to mental illness are returned from court instead of
24
ending up in another prison. If the PER had been adequately explanatory, the
relevant court staff would have been able to make an informed decision as to
whether or not he should return to Peterborough. However, the failure to
provide sufficient explanatory detail meant that the information which should
have been immediately available to Leicester’s staff was absent.
95. The man was not actively considered to be at risk of self harm, his symptoms
had been stabilised by medication and the PER prepared by Peterborough did
not mention his schizophrenia. Had the PER requested that he was returned
to Peterborough, in all probability he would have been. However, in terms of
priority for return to a prison after a court appearance rather than spending the
night in a police cell, the man’s PER did not flag up that he was a possible
risk. This meant that instead of returning to Peterborough, where he lived and
his mental health needs were addressed, he was taken to spend the night in a
police station in Northamptonshire and then on to HMP Leicester the next
day, where he was unknown.
I recommend that the Director of Peterborough devises a system to
ensure that up-to-date healthcare information is included on PERs
before each escort takes place.
I recommend the Director of Peterborough ensures that explicit requests
for individual prisoners to return to Peterborough are made on PERs if
the circumstances warrant it.
96. The man’s telephone conversations with his sister give the impression that he
was expecting to return to Peterborough after his court appearance. Indeed
his personal nurse told my investigator she did not think he would spend long
at Leicester and that he would have returned to Peterborough because he
was due to attend court there. It certainly would have made sense for him to
have returned there. Both the prison in-reach and the community outreach
teams knew the man very well as he had been their patient for some ten
years. He had worked with the some of the same practitioners for several
years and they were familiar with his background.
97. One might well ask whose responsibility it was to arrange for the man to be
returned to Peterborough. He, not unreasonably, assumed that he would be
returned to Peterborough because he was due to appear in court. His
personal nurse assumed that he would be returned in due course. His
allocated personal officer was on leave and his former CPN at Peterborough
was unaware of his location. There is no clear policy on the responsibility to
initiate a transfer in such circumstances. Perhaps if the man had made a
formal request to return, then the ball would have begun to roll, but there is
nothing to suggest that he did. He had only spent a week at Leicester and
was still feeling his way. Peterborough in-reach told my investigator that if
Leicester had approached them for information rather than contacting the
Assertive Outreach Team in the community, arrangements could have been
made for the man to return.
25
98. Due to the slight expansion of prison places since the time of the man’s death,
Operation Safeguard has not been re-activated for some time. Regrettably,
however, the prison system is still experiencing the twin phenomena of
increasing turnover of unconvicted prisoners between prisons and an increase
in absolute numbers of prisoners. This puts prisoners in the vulnerable
position of being liable to be moved around the country in an effort to
overcome the geographical imbalance between spaces available and their
location. This is not good for prisoners or prisons.
99. The man’s Cell Sharing Risk Assessment (CSRA) at Peterborough assessed
him as being medium risk, which meant that there was no immediate risk but
the situation would need to be reviewed regularly. When he arrived at
Leicester, he was assessed as low risk, despite the existing CSRA. The man
shared a cell with two different prisoners before his risk was reviewed on 25
May and upgraded to high, following which he was placed in a single cell. I
have not seen documents that show he had assaulted other prisoners in the
past. Nevertheless, the issue of whether or not to allow a prisoner with a
raised risk assessment to share a cell raises important questions of how one
deals with prisoners who could pose a risk to others balanced against the risk
such prisoners pose risk to themselves. I accept that such assessments are
an essential tool for prison staff and I support their use. The difficulty in this
man’s case is that his high risk status gave rise to the unintended
consequence of him missing human contact. It is unclear whether he had
possessions at his disposal such as a radio, television, reading material or
other means to be able to stave off the loneliness he was experiencing.
I recommend that the Governor of Leicester assesses the needs of high
risk CSRA prisoners and devises means to alleviate the effects of
isolation.
100. The man remained in the relatively sheltered environment of the First Night
Centre for a week before moving upstairs to L4 landing on 30 May. Having
had the opportunity to share a cell, albeit inadvertently, it is striking that there
is a constant thread of him asking several times if he could have a cell mate
because he was lonely. As an officer commented, the man spoke of feeling
lonely all the time. When he had the opportunity to mix with other prisoners,
initially he had played table tennis with his cellmate and chatted. By the next
day, however, he appeared to have retreated into himself, returning to his cell
early after telling an officer that he was uncomfortable socialising with a large
group of prisoners. Ironically, the information that the man did not like large
groups of people was provided by Peterborough’s in-reach team in the
minutes of the Public Protection Panel (PPP) meeting which took place on 10
May and were in the man’s prison records. If contact had taken place
between the two in-reach teams, crucial facts about the man could have been
handed over promptly rather than Leicester having to tease them out from a
thick file which was not readily available to landing officers. Awareness of
such information could have enabled officers to understand the significance of
the man’s behaviour. Unfortunately, the fact was buried in his records.
26
101. On the day the man died he asked, not for the first time, for his observation
panel flap to be left open so he could see people passing outside his cell.
This was done, although the flap appears to have been closed by the time his
personal nurse reached his cell. The man told an officer that he intended to
raise the issue of cell sharing with his in-reach nurse. He was suffering from
schizophrenia, he had been recalled to prison after serving a sentence for a
serious act of violence, he was facing further charges which, if proven, could
have resulted in a lengthy prison term, he was in an unfamiliar prison, his
family had been unable to arrange a visit and he spoke repeatedly of feeling
lonely. This combination of factors, in retrospect, meant that the man was
more vulnerable than was realised. However, they were not facts that any
one member of staff had been able to pull together. An officer’s interaction
with the man revealed an understanding and caring approach which reflected
well on him. I appreciate that busy local prisons are not the easiest of
environments for staff to get to know those in their care especially in only one
week but it is possible that if the man had been able to spend some time with
his personal officer, these apparently disparate strands could have been
drawn together.
I recommend that the Governor reviews and strengthens the role of the
personal officer at Leicester.
102. A clinical review of the medical treatment the man received in custody was
conducted by a doctor on behalf of Leicester City Primary Care Trust. His
report said that there were no indicators that the man was becoming psychotic
whilst in Leicester apart, possibly, from the observation by an officer that he
was walking on the spot in his cell. The man did not express delusions about
the devil or his religion but it was possible that he was in the early stages of
relapse. He stopped collecting his Olanzapine medication after being
transferred and he may not have taken it even on the days he did collect it.
The doctor said that on first examining the man’s prescription charts, he had
wrongly assumed that the initials DNA next to certain dates denoted the
member of staff who had issued the medication that day. It was only
sometime afterwards that he realised DNA in fact stood for ‘Did Not Attend’.
He makes the point that on looking at the charts, this error is all too easy to
make. The review continues:
“If the fact that the man had stopped collecting his medication had
been carefully analysed it might have triggered an early mental health
assessment, which might possibly (although I would not put it any
higher than this) have picked up signs of distress. Support might then
have been able to be given to the man that might have prevented any
self-harming actions. It is, however, worth noting that the man had not
exhibited major self-harming behaviour in the past and his fatal self
harming action might have been an impulsive gesture in response to
the stress of the charges he was facing. Such impulsivity might have
increased by his decision to stop taking his Olanzapine”.
103. The clinical reviewer notes that the man’s clinical record contained information
that he was known to be at risk of rapid relapse into psychotic illness if he
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stopped taking his medication. Whilst a care team who were familiar with him
would have known this, it was not flagged up to Leicester who had to rely on
combing through his “voluminous” files to extract pertinent information.
104. The Clinical Reviewer made several recommendations including:
“I therefore recommend that prison primary and specialist
healthcare services should work to identify prisoners whose
health, physical and mental, is known to be at risk of rapid
deterioration and to ensure that such information accompanies
the prisoner, in real time, around the prison system. This will
require negotiation with prisoners in respect of confidentiality of
information.”
“I recommend that the primary healthcare service at HMP
Leicester considers updating its coding system so that the entry
representing the fact that a patient has not collected his
medication cannot be mistaken for an entry that represents the
fact that he has collected it.”
“I recommend that the primary healthcare service at HMP
Leicester considers drawing up a protocol to ensure that if a
prisoner decides not to take prescribed medication the matter is
brought to the attention, in a timely manner, of a healthcare
professional with sufficient knowledge and skills to decide what
action (if any) should be taken. Such a decision should be
documented in the patient’s clinical record.”
105. The clinical review raised a number of important questions about the
healthcare the man received at Leicester. The clinical reviewer focuses on
whether the man was becoming psychotic, the clinical information available
about the man and the systems at Leicester for recording whether medication
had been administered.
106. The Clinical Reviewer’s report says that there were no indicators that the man
was becoming psychotic apart from, possibly, when the officer observed him
walking on the spot in his cell. He acknowledges that the man appeared to be
becoming more stressed a week or so before he arrived in Leicester.
107. On five of the nine days that the man spent at Leicester, he did not collect his
medication. His prescription chart was marked ‘DNA’ when he failed to
appear. SERCO’s investigation report says that a nurse informed the in-reach
team about this and left it to them to take forward. The man’s personal nurse
appears to have been unaware of this and said the man told her that he was
taking his medication and felt well. There appears to be some confusion as to
who knew what. The toxicological analysis of the man’s blood and urine did
not reveal traces of identifiable medication but specific tests to show their
presence may not have been performed. The man’s clinical record showed
that he had missed several doses but I have not seen any written
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documentation to indicate that the in-reach team were aware that he was not
taking his medication.
108. It may be that the man decided not to take his medication or he might have
failed to collect it for some other unexplored reason. Unlike in the local
community, the free movement of prisoners is limited and it is the prison’s
responsibility to enquire. It is important that there is adequate follow up
especially when the medication is for a mental health condition. In a previous
report on the death of a prisoner at Leicester who died in January 2007, I
made a recommendation concerning the importance of following up any
prisoners who have missed their medication. I concur with the clinical
reviewer’s recommendations in this regard.
109. The man was known by Peterborough to be at risk of rapid relapse into
psychotic illness if he stopped taking his medication. A care team who were
familiar with the man would have known this, whereas Leicester had to comb
through the many documents in his clinical record to extract the relevant
information. If the man’s personal nurse had examined the man’s most recent
Medication Administration Record Chart before she went to see him, she
would have seen that the man had missed his medication for several days.
Whilst there is a reference by a nurse in the man’s clinical record to contacting
the outreach team, I have seen nothing in the man’s records to indicate that
contact between Leicester’s and Peterborough’s in-reach teams did in fact
take place. Peterborough told my investigator that Leicester did not contact
them and his personal nurse could not recall if anyone at Peterborough had
spoken to her. Clearly, this was unsatisfactory. There is no way of knowing
whether the man might have taken his life at Peterborough at some point in
the future rather than at Leicester, but close liaison between the in-reach
teams would have helped minimise the risk that vital information between the
two would be lost. This is also an example of relevant information that could
have been written on his PER. I concur with the clinical reviewer’s
recommendation in this regard.
I recommend that prison primary and specialist healthcare services
should work to identify prisoners whose physical or mental health is
known to be at risk of rapid deterioration and to ensure that such
information accompanies the prisoner around the prison system.
Good Practice
110. It was good practice for the prison Reverend and a Principal Officer from HMP
Leicester to travel the 103 miles to London to tell the man’s family personally
of his death rather than asking the police or a governor at a prison nearer to
the family home. This showed care and consideration for the man’s family
and is in keeping with previous deaths I have investigated where Leicester’s
impressive family liaison has been praised.
111. It was good practice for the man to be able to move easily between healthcare
and his houseblock at HMP Peterborough according to the state of his mental
29
health. This appears to have been well managed, with houseblock staff
aware of his situation.
30
RECOMMENDATIONS
To the Director of Peterborough
I recommend that Peterborough devises a system to ensure that prisoners
who attend court or leave the establishment are recorded on System 1.
After consideration of the draft report, the Prison Service accepted the
recommendation and responded, ”All prisoners transferred from HMP Peterborough
to court or to another HMP establishment will have their records on System One
updated by a suitably trained person and a copy of the System One record will be
placed with the IMR in the transfer envelope.” It gave a target date for completion as
October 2008.
The six month follow-up action plan progress report said “All staff have now been
trained on System One and ongoing support is in place. All records are input on to
System One by trained nurses.
I recommend that the Director of Peterborough reminds staff that signatures
on documentation must be legible.
The Prison Service accepted the recommendation. The six month follow-up action
plan said “All staff will be reminded by way of a notice about the importance of
legible signatures, printed name and designation on documentation. This will also
be raised during induction of operational and non-operational staff. Registers of
names, designations, signatures and initials will be maintained for all staff
(healthcare, permanent and agency and custodial) based in male and female
healthcare.” It gave the target date as October 2008.
The six month follow-up action plan progress report said “A signature register is now
in place.”
I recommend that the Director at Peterborough devises a system to ensure
that up-to-date healthcare information is included on PERs before each escort
takes place.
The recommendation was accepted. The Prison Service responded “Staff
completing Healthcare information will receive adequate training to ensure all
information is documented prior to an escort. An information folder will also be
provided for staff which details how the documentation should be completed.” A
target date of October 2008 was given.
The action plan progress report said “Registered Mental Nurses are now based in
reception. They sign all PERs and input required information on to the system.”
I recommend the Director of Peterborough ensures that explicit requests for
individual prisoners to return to Peterborough are made on PERs if the
circumstances warrant it.
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The recommendation was accepted. The Prison Service responded “Requests for a
prisoner to return to HMP Peterborough on medical grounds will be noted on the
PER prior to discharge.” A target date of October 2008 was given.
The action plan progress report commented “This is ongoing. A list of prisoners on
medical hold is available to the doctor on a spreadsheet. The doctor is aware to
print the sheet daily and share the information as required.
To the Governor of Leicester
I recommend that the Governor of Leicester assesses the needs of high risk
CSRA prisoners and devises means to alleviate the effects of isolation.
The recommendation was accepted. The Prison Service commented: “There is a
robust weekly risk assessment process in place that reviews all prisoners who are
high risk and require a single cell. The CSRA review process will be amended to
include a plan to minimise the isolation of prisoners who are potentially vulnerable or
are displaying mental health or other concerns.”
The progress reported that the recommendation had been completed and the weekly
CSRA meeting is “now embedded, this meeting reviews all High Risk single cell
prisoners.
I recommend that the Governor reviews and strengthens the role of the
personal officer at Leicester.
The Prison Service accepted the recommendation and commented: “There was a full
review of the personal officer scheme at Leicester in June 2007. The new process is
now fully embedded and the recent HMCIP inspection acknowledges that although
basic, the scheme was effective.
The progress report said that the recommendation had been completed. “The
residential Principal Officer now conducts a weekly management checks on a
random sample of personal officer entries, this helps to ensure staff make
appropriate and meaningful entries of interactions with prisoners.
The Governor and the primary healthcare provider: SERCO
I recommend that the primary healthcare service at HMP Leicester considers
updating its coding system so that the entry representing the fact that a
prisoner has not collected his medication cannot be mistaken for an entry that
he has collected it.
This recommendation was partially accepted. The response read “The coding used
at HMP Leicester is common to most prisons in the UK so a decision to change
coding would need to be taken at a higher level.
The progress report commented “System One, the healthcare medical records
system has a generic coding system built in. When a patient does not collect their
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medication free text is also entered on the system against that prisoner, this process
was audited in January 09 and found to be 98% positive.”
I recommend that the primary healthcare provider at HMP Leicester devises a
protocol to ensure that if a prisoner does not collect their medication, the
matter is brought to the attention, in a timely manner, of a healthcare
professional with sufficient knowledge and skills to decide what action (if any)
should be taken. Such a decision should be documented in the patient’s
clinical record.
The recommendation was accepted. “Staff information notice issued as evidenced in
the report. Management and pharmacy checks carried out on a regular basis.” The
follow-up action plan said that “management checks instigated June 2007 and on-
going.”
The progress report commented “Healthcare staff complete omit code checking and
this was recently audited as above. A notice to staff was issued, and a reminder
notice to staff is to be re-issued to ensure continued compliance.”
The Governor and the PCT Prison Health Lead
I recommend that prison primary and specialist healthcare services should
work to identify prisoners whose physical or mental health is known to be at
risk of rapid deterioration and to ensure that such information accompanies
the prisoner around the prison system.
The recommendation was partially accepted. The action plan commented “The PCT
has commissioned SERCO to provide co-ordinating role. The PCT will work with
SERCO to devise a new protocol and risk management tool using principles of the
Offender pathway. This will be an agenda item for the SERCO performance
management meeting on 8 October 2008.
The progress report said “The Clinical Governance committee now have a formal
review process in place for all of SERCO’s working protocols. A review of the mental
health provision has been completed, the PCT have agreed a new contract giving
increased mental health cover for HMP Leicester and this will be effective from
1/6/2009. All relevant health information accompanies a prisoner if they move
around the prison estate.
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GOOD PRACTICE
It was good practice for the prison Reverend and a Principal Officer to travel
the 103 miles to London to tell the man’s family personally of his death rather
than asking the police or a governor at a prison nearer to the family home.
This showed care and consideration for the man’s family and is in keeping
with previous deaths I have investigated where Leicester’s impressive family
liaison has been praised.
It was good practice for the man to be able to move easily between healthcare
and his house block according to the state of his mental health. This appears
to have been well managed, with house block staff aware of his situation.
No comments were received concerning good practice.
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