Individual at Bristol

Investigation into the circumstances surrounding the
death of a male prisoner at HMP Bristol,
on 25 September 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2010
1
This is the report of the investigation into the circumstances surrounding the
death of a man. The man was found hanging in his cell on A wing at HMP
Bristol on 25 September 2009. He had been in custody for twelve weeks.
An investigator from my office has undertaken the investigation. I would like
to thank the Governor of Bristol, and his staff for their participation. Bristol
Community Health was commissioned to undertake a review of the man’s
clinical care while at Bristol. A Clinical Reviewer was appointed by them to
conduct the review and I thank him for his report.
I would like to add my condolences to those already expressed by the
investigator and the Family Liaison Officer, to the man’s family and friends.
The man had been a remand prisoner at Bristol since 4 July 2009 and worked
as a landing cleaner on A wing. In late August, a member of staff became
concerned about the man and, following an assessment, it was decided he
would benefit from a period away from the wing. He was admitted to the
healthcare wing where he was diagnosed with reactive depression. He
declined the offer of antidepressants but accepted medication to help him
sleep. After a week, he returned to A wing and was described as upbeat and
talkative. Neither staff nor the man raised any other concerns after his return,
but his family consider he might have masked his feelings.
On 25 September, wing staff unlocked prisoners at around 8.10am and began
the morning routine. A fellow prisoner, who was also a cleaner on the landing
with the man, went to his cell as he had not come out to begin cleaning and
discovered him hanging by a ligature from the end of his bed. Staff went into
the cell, cut the ligature and checked for signs of life. However, it was
apparent to them that the man had been dead for some time and cardio
pulmonary resuscitation was not attempted. A prison doctor, (Doctor A)
confirmed the man’s death at 8.58am.
In the draft report, I said that with hindsight, it might have been appropriate to
implement Assessment, Care in Custody and Teamwork (ACCT) procedures,
which provide additional support for prisoners at risk of harming themselves.
Following the issue of the draft report, the man’s family provided new
information to the investigator. Further enquiries were then made which
revealed evidence that the man’s family had raised concerns about his
welfare before his death.
Six recommendations were made relating to ACCT procedures and training,
mental health assessments, roll checks and information from prisoners’
families. Four of these have been fully accepted by the prison and a further
two partially accepted by the healthcare department. I make an additional two
recommendations in relation to dealing with information from prisoner’s
families.
Jane Webb
Acting Prisons and Probation Ombudsman May 2010
2
CONTENTS
Summary 4
The investigation process 6
HMP Bristol 7
Key findings 9
Issues 21
Conclusion 26
Recommendations 27
3
SUMMARY
The man was remanded into custody to HMP Bristol on 4 July 2009. This
was his first time in custody. On his reception at Bristol, a nurse conducted a
health screen. The man disclosed no previous physical or mental health
concerns during the screening and said that he had no thoughts of harming
himself. The nurse advised him to speak with a member of staff if he began
feeling less stable at any point.
He was then located onto A4, which is the first night landing. Although
prisoners usually only spend a short time on A4 before moving to other wings,
the man was considered mature in his approach and offered a job as landing
cleaner which he happily accepted. He was also asked to act as an Insider
and talk to other new prisoners on their first night in custody. (Insiders are
volunteer prisoners who offer advice and support to other prisoners when they
first enter custody and at other times as required.)
The man settled in well to the regime and built a good rapport with staff and
fellow prisoners. Staff considered him to be coping well and had no cause for
concern. In spite of staff perceptions, during visits from his family and in
telephone calls he spoke about feeling that he would never get out of prison
and appeared to them to be very depressed. The man had been refused bail,
which was a shock to him. He began to feel that people were passing
information to the police and he had various anxieties about his future.
However, despite these concerns, on the wing he portrayed a person who
was coping and would happily go about his daily tasks and share a laugh with
staff and other prisoners.
On 25 August, the man asked to speak with Officer A who regularly worked
on A4 and had known him since he arrived at Bristol. He expressed concerns
about his case and Officer A felt that he appeared down and not himself. As a
result, the officer asked for a member of the healthcare staff to assess him on
the wing. Later that day, a nurse spoke with the man and he confirmed that
he was feeling low. He also spoke about a family history of depression and
the suicide of his sister, the first time he had mentioned this. The nurse
considered that he would benefit from a period away from the wing and
arranged for him to be admitted to the healthcare wing later that day.
Arrangements were also made for him to be seen by a doctor and the Mental
Health In-Reach Team (MHIRT). A mental health nurse assessed him and
diagnosed reactive depression (when depression is triggered by a traumatic,
difficult or stressful event). The man declined the offer of medication to help
with his symptoms. He denied any thoughts of self-harm and returned to A4
landing after a week.
After the man returned to the wing, staff and fellow prisoners commented that
he appeared much happier and he continued with his cleaning job. However,
in telephone calls to his family he continued to be distressed and spoke of
feeling that he would never be released. During visits, his family said they
noticed a visible decline in his appearance and described him as low in mood,
tearful and paranoid.
4
On 24 September, the man spent the day cleaning as usual and appeared his
normal self, interacting with staff and other prisoners. Although it could not be
confirmed, it is likely that he had spent time out of his cell during the evening.
He was locked in his cell at 7.00pm. A roll check was carried out at this time
and no problems were reported. During the night, no problems were reported
and an Operational Support Grade (OSG) carried out a further roll check at
5.30am on 25 September. (An OSG is the grade below a prison officer.)
When the OSG checked the man’s cell, he observed what he thought was
someone in the bed and no concerns were raised. Officers arrived for the day
shift at 7.30am, and unlocked all the cells on A4 at around 8.15am. Officer B,
who unlocked the man’s cell, looked in and also saw what he thought was
someone under the bed covers. He said good morning and moved on to the
next cell. The two officers then dealt with queries from prisoners.
At 8.40am, a fellow prisoner who cleaned with the man became concerned
that he had not seen him and went to his cell to check that he was out of bed.
At first, he stood by the door and could not see anything untoward. However,
as he walked further into the cell he saw the man hanging by a ligature at the
end of his bed. He immediately left the cell and called for the officers to
attend.
Officer A was the first to go into the cell, and initially he could not see a
problem, the man was at the back of the cell and a locker had been placed to
hide him from view of the doorway. As he went further into the cell, he saw
the man and called for Officer B to assist him. The two officers tried to lift the
man and Officer A cut the ligature attached to the man’s neck. Once the
ligature had been removed the man was checked for any signs of life, but no
pulse or breathing could be detected. Officer A said that it was clear to him,
from the man’s appearance that he had been hanging for sometime.
Additional staff arrived, including healthcare workers who also checked for
signs of life but again concluded the man had been dead for sometime and
that cardio pulmonary resuscitation would not be of any benefit. Doctor A,
confirmed the man’s death at 8.58am.
Prison staff broke the news to the man’s family and kept in regular contact
with them during the subsequent arrangements.
My recommendations cover appropriate implementation of ACCT and mental
health assessments, as well as updating the documents for roll checks and
the handling of concerns raised by prisoners’ families.
5
THE INVESTIGATION PROCESS
1. Notices informing both staff and prisoners of the investigation were
issued on 28 September. They invited anyone who had information
about the man’s death to contact the investigator. No responses were
received.
2. The investigator, telephoned the prison initially on 25 September and
again on 28 September. He spoke with the Deputy Governor, to arrange
for the man’s prison and medical records to be made available to him.
The investigator visited Bristol on 30 September with a colleague, when
they met the Deputy Governor and members of the senior management
team. The investigator also viewed the cell occupied by the man on A
wing and briefly spoke to staff and prisoners who had known him.
3. The investigator and his colleague visited Bristol again on 4 November,
and conducted interviews with four members of staff who were in regular
contact with the man or involved with him during his time at Bristol.
Transcripts of these interviews are attached as annexes.
4. Bristol Community Health were commissioned to conduct an
independent review of the medical care that the man received in custody
at Bristol. The man had very little contact with healthcare while in
custody and the Clinical Reviewer was asked to look at the mental
health assessment that the man had in August 2009. I would like to
thank the Clinical Reviewer for his report.
5. The next of kin details provided by the prison indicated that the man had
been separated from his wife for some time but they were still close
friends and in regular contact. The man’s father and partner also
remained in regular contact. The Family Liaison Officer telephoned and
wrote to the man’s family and they accepted her offer to visit them at
their home.
6. During the visit on 10 November, the Family Liaison Officer explained
the investigation process again and the investigator apprised the family
of his investigation to date. The man’s family said that they were
concerned that prison staff had not noticed the deterioration in the man’s
mental wellbeing sooner and that he had not been subject to closer
monitoring. These and other matters raised by the man’s family are
addressed within the report. I hope the findings provide them with a
better understanding of the events leading up to his death.
7. The investigator contacted HM Coroner to inform him of the nature and
scope of the investigation and to request a copy of the post mortem.
The post mortem concluded that the man died as a result of hanging.
6
HMP BRISTOL
8. HMP Bristol is a local prison, located in a largely residential area in the
middle of the city. It can accommodate up to 606 adult male prisoners
across seven wings with an additional healthcare unit. The first night
centre is located on A wing along with the induction landing and
detoxification. A regular staff group work on the first night centre and
cover additional duties in the reception in the evenings.
9. Bristol PCT provides healthcare and the healthcare centre provides 20
in-patient beds. Mental health services are provided by Avon and
Wiltshire Partnership Trust and six registered mental health nurses
provide support to prisoners on a full-time basis.
10. HM Chief Inspector of Prisons carried out an unannounced inspection in
March 2008 following a previous inspection in 2005. She reported that
the Inspectorate “were extremely encouraged by the significant
developments in all aspects of health services”. In a recommendation
regarding the transfer of healthcare services at Bristol, HM Chief
Inspector of Prisons said:
“There were robust links between the establishment and the
PCT. Health services were strongly supported by the Governor
and there was robust and effective operational and clinical
leadership. Health services were fully assimilated into the
regime and there were innovative working practices in the
healthcare department. All health services staff were employed
by one of three organisations: the PCT, the Avon and Wiltshire
Partnership Trust or the prison. However, from May 2008, staff
would only be employed by either the PCT or the Avon and
Wiltshire Partnership Trust. Staffing and managerial issues
were beginning to reach a steady state and there were only two
nursing vacancies at the time of the inspection. There had been
a lengthy period of staff sickness but this had been addressed
through the occupational health service. Administrative support
was efficient, and current staffing levels and skill mix were good,
and included registered nurses, healthcare officers and
healthcare assistants. PCT bank nurses were used where
necessary and the number of agency nurses had been
significantly reduced.”
11. With regards to self-harm and suicide, HM Chief Inspector of Prisons
had recommended in her initial inspection that there should be a safer
custody strategy to help reduce the risk of self-harm and clarify the role
and responsibilities of Listeners. (Listeners are trained by the
Samaritans to provide emotional support to fellow prisoners in distress.
ACCT is a process for monitoring and supporting prisoners at risk of self-
harm and suicide.) During the follow up inspection the HM Chief
Inspector of Prisons found that the prison had achieved this and in her
report said:
7
“The prison had recently written a new safer custody policy
document which was comprehensive and outlined, among other
things, the role and responsibilities of Listeners. It also provided
information about the detailed systems for supporting prisoners
on open Assessment, Care in Custody and Teamwork (ACCT)
documents.”
12. Every prison in England and Wales has an Independent Monitoring
Board (IMB). The members are volunteers who monitor the day-to-day
life in their local prison and ensure that proper standards of care and
decency are maintained. The Bristol Independent Monitoring Board’s
(IMB) annual report 2006/07noted the “high quality of staff and prisoner
relations”. They welcomed the commissioning of healthcare by Bristol
PCT and the review of the necessary skills mix that accompanied it.
They also refer to Safer Custody provision and conclude:
“Safer Custody and Violence Reduction are handled with
professionalism and enthusiasm by the allotted team in
conjunction with the PSO 2700 guidance.
“It is, however, worth observing that prison officers should not
have to cope with the many mentally ill prisoners in an
establishment not designed for purpose, whilst they do handle
such prisoners with care and respect, they are not mental health
nurses albeit they receive some mental health training.”
13. Since 2004 when the Ombudsman began investigating all deaths in
prison custody there have been five deaths at Bristol, which were self-
inflicted. There were, however, no direct similarities between these and
that of the man.
8
KEY FINDINGS
14. The man was remanded into custody at HMP Bristol on 4 July 2009.
This was his first time in prison. On arrival at the prison, a nurse
assessed him and completed an initial health screen. The nurse asked
various questions about his existing and previous health concerns. The
man replied that he was not receiving treatment at that time and had no
medical problems. The nurse also explained that some people find
coming into custody difficult and might consider harming themselves.
She asked him if he felt that way, to which he replied, “I don’t think so”.
In relation to his mental health, the man said that he had no problems
and clarified that he had never been seen by a psychiatrist or received
medication for his mental health. The nurse recorded in the man’s
medical record that there were no notable medical needs and that she
had advised the man to speak to either an officer or wing nurse if he felt
less stable.
15. Following the reception process, the man was located onto A4 landing,
which is the first night centre. Over the next few days, the man went
through a full induction during which he was informed of the rules and
services on offer at the prison, including access to the Samaritans and
other support services. It is normal for prisoners to move on to one of
the other wings once they have completed the induction. However, the
man was considered by staff to have the right attributes/qualities to
become a landing cleaner and also offer advice and support to other
new prisoners. This is a role known in the prison as an ‘Insider’. He was
pleased to be given the opportunity to work so soon after arriving and
was said to be happy to provide support to fellow prisoners.
16. Staff on A4 landing described him as a very likeable man who was hard
working but could also be quiet and was careful who he spoke to about
personal matters. Officer A had known the man since he arrived at
Bristol and worked regularly on A4 landing. He told the investigator, that
he would often speak with him about his case or his family and he
always appeared upbeat. The man was also well thought of by other
prisoners who knew him from the local community. Although located on
different wings shortly after his arrival, some of them put together a few
items to help him settle in, as they knew that he had arrived with very
little. He received regular visits from his father, wife, children, partner
and friends. The man also telephoned his children regularly.
17. The man worked hard in his role as landing cleaner and received
favourable reports from wing staff. He remained positive when dealing
with both staff and other prisoners and gave no cause for concern.
However, after his death the investigator had the opportunity to listen to
telephone calls made during the man’s time in custody. It is apparent
from the calls that he was not coping with being in custody and being
away from his, family as well as he had led people to believe. Although
prisoners are advised on reception that telephone calls may be
monitored, not all calls are routinely listened to. Only those prisoners
9
who are subject to certain restrictions or considered a security risk will
have all telephone calls listened to. The man was not considered to be
in either of these groups. The man’s father told the investigator that he
found it difficult to understand why his son’s telephone calls were not
subject to routine monitoring, given that his case was considered serious
enough for him to be refused bail. As mentioned above, the criteria for
monitoring telephone calls is based on the need for public protection and
security, and not necessarily the circumstances of individuals’ offences.
18. The man had been refused bail as the court considered he might
escape. The decision might have been influenced by the fact that he
owned property abroad. The refusal to grant bail was something that
caused him concern. The man was worried that he would never get out
of prison and he expressed these concerns to his family during visits.
He also reportedly spoke to another prisoner on A4 landing with whom
he had been friends in the community. He spoke of his concern that he
was going to lose everything that he had worked so hard for and his
family would be left with nothing. During these conversations, the man
spoke about a confiscation order against him.
19. The investigator contacted the police officer dealing with the man’s case
to ask what actions were being taken against him. The officer confirmed
that the man was held on remand for possessing an imitation firearm as
well as a second charge of allowing premises to be used for the
cultivation of cannabis. The officer said that the police were still in the
process of investigating the case when the man died. The officer
explained that a confiscation order would only be made if he had been
convicted of a drugs offence. Given there had been no conviction, the
police had not considered this or mentioned it to the man.
20. The man’s wife told the investigator that she visited her husband with
her daughter in August and they were concerned by his appearance.
She said that he was looking very down and it was like “the lights were
on but no one was in”. She said that she reported her concerns to an
officer on duty in the visits room who initially said that nothing could be
done unless the man himself asked for help. However, after insisting
that her husband was spoken to, officers asked him whether he was all
right and he replied that he was. The man’s wife felt that her husband
was unlikely to say anything different in this setting. She said that he
kept asking questions and seeking reassurance that she would look
after his mother and children. She said that, in hindsight, it seemed as
though he was making sure that everyone would be looked after.
21. The man’s wife also said that another prisoner, in custody at the same
time as her husband, mentioned an occasion when the man had to be
helped from the shower. He had been seen standing, motionless, in the
shower for a long time and prisoners alerted staff who intervened and
helped him back to his cell. The investigator spoke about this to Officer
B who worked regularly on A4 landing. Officer B said that he was not
aware of any such problem with the man and had not seen anything
10
documented about this. He believed that if this had taken place it was
significant enough for all regular landing staff to have been made aware
of it. It is not possible to clarify whether the events described took place,
as there is no documentary evidence.
22. The man’s father also told the investigator that he had been concerned
about his son when he visited him. He explained that his son appeared
to become very low and repeatedly said that he was not going to get out
of prison. He could not understand why his son kept saying this and
continued to reassure him that everything would be all right. The man’s
family said that during a visit he told his daughter that he had some
‘good news’ and appeared optimistic. However, his father told the
Family Liaison Officer that when his son spoke to his partner on the
telephone the following day he was in tears and very low. The man’s
father was concerned that something had happened to him during this
period to affect his mood. During the investigation, no evidence was
found to suggest that anything of significance happened to explain the
change in the man’s mood.
23. The investigator was also told by the man’s father that his mother had
contacted the prison via a telephone helpline (described later in this
report) in order to inform them of the family history of depression. She
left a message and was told that someone would contact her, but the
man’s father said that to his knowledge this did not happen. The
investigator examined the log of calls received by the prison helpline
during the period the man was in custody and no calls are recorded in
relation to him.
24. However, following the issue of the draft report, the man’s father
contacted the Family Liaison Officer, and provided a telephone number
that the man’s mother had called on 24 August. The Family Liaison
Officer shared this information with the investigator who in turn contacted
the Deputy Governor at Bristol. The Deputy Governor said that he would
attempt to identify the telephone number, as it did not appear to be a
recognised prison contact, and get back to the investigator.
25. While he was awaiting the man’s response, the investigator contacted
the man’s father to try to gain more information about the call. The
man’s father explained that his ex wife had obtained the number from a
leaflet that she had received from the prison. The investigator identified
that the leaflet related to the Prison Advice and Care Trust (PACT) who
run the visitor’s centre at Bristol. The investigator then telephoned the
Deputy Governor, who had by this time also identified that the call had
been made to PACT. He told the investigator that he had spoken with
the member of staff who runs the visitor’s centre (Staff A) and that he
was looking back through the records to trace the notes of any calls
received.
26. Staff A found the notes that he had made following the concerns raised
by the man’s family, which also documented the action that he had
11
taken. The Deputy Governor passed these to the investigator. Staff A’s
notes say:
“ … The man’s mother rang because she is concerned about
change in his behaviour since he came in. When she visited
last Thursday, he and stared into space most of the time. Said
he is not sleeping. People who have visited since say that he
has got worse. He said he is ok. I gave her the self-harm
number to ring if she sees him again on Friday and is still
concerned.
I rang Mental Health team who will put him down for
assessment. It could just be normal reaction and adjustment,
but they will put on list so it could be either Tuesday or
Thursday. Gave them mothers’ telephone number but they will
not necessarily ring …”
27. There is no evidence that the information received by Staff A on 24
August was shared with wing staff. On A wing, the impression that the
man portrayed to staff did not give them any cause for concern. Regular
wing staff said that he continued to go about his cleaning work as usual
and, although never overly talkative, would chat with staff as he did so.
However, on 25 August, the man asked to speak in private with Officer
A, who also worked regularly on A4. The investigator asked Officer A if
he could recall what the man wished to talk about. He replied that the
man told him that the police had asked him about dates, mobile
telephone numbers and bank accounts. He was concerned that there
was a conspiracy against him or someone had been “grassing him up”.
Officer A said that the man appeared to struggle to understand where
their information had come from. Officer A told the investigator that he
did not know the man’s case so was unable to offer any real advice.
28. In response to the draft report, the man’s father also raised concerns
that his son was being placed under undue pressure from the police in
relation to his case. He asked whether his son would have been
interviewed by the police without his solicitor present. When an
individual is in custody and the police are continuing to make enquiries
into the alleged offences, they can arrange to visit the prison to conduct
an interview. The police will book the visit with the prison in the same
way as other legal visits and the prisoner will be notified so they can
arrange legal representation. If a prisoner has no legal representation,
prison staff will ask the individual to confirm they are happy to proceed
before the interview takes place. It is not clear when the police visited
the man, but it is unlikely that such a visit would have been conducted
without his solicitor being present.
29. The investigator asked Officer A if their conversation had led him to have
concerns about the man. The officer said that a prisoner discussing his
case would not in itself cause concern as this often happened but he had
felt that something was not right. He was concerned about the way the
12
man carried himself and considered he was very quiet, even though he
was talking. Officer A said the man seemed to be having a conversation
with himself, trying to work things out and just needed someone there to
listen.
30. Officer A said that after the conversation, he telephoned the healthcare
department to ask someone from the Mental Health In-Reach (MHIRT)
to go and speak with the man. No one was available but, the nurse who
took the call agreed to speak to him and did so within the hour. The
nurse recorded:
”… Has been in prison for approximately seven weeks,
working as cleaner on 4’s landing but last few days officers
have been worried that he has become withdrawn. Spoke with
the man, very withdrawn, and unkempt, wringing hands and
head in hands. Says that he has history of depression in his
family and sister committed suicide at the age of 26, mother
clinically depressed. The man has never been in custody
before. Never been treated for depression. Not eating at
present and has lost a lot of weight. Not sleeping well and has
not telephoned home to wife and children for last couple of
days. To be admitted to healthcare for full mental health
assessment. Feels helpless at present and unable to make a
decision for himself. Is agreeable to being admitted to
healthcare, Doctor A informed …”
31. From the entry made by the nurse it would appear that she was unaware
of the call made by the man’s mother, and the conversation that Staff A
had with the Mental Health team. This was the first record of the man
mentioning his family history of mental health problems. When asked
about the man’s reaction to being told that he was to be admitted to
healthcare, Officer A said he thought that the man was looking forward
to spending some time away from the wing to be able to reflect on
things. The man was admitted to the healthcare wing later that
afternoon.
32. The man’s father asked about the qualifications and suitability of nursing
staff conducting mental health assessments. It is the case that not all
nursing staff in the prison have a mental health background, but general
nurses are able to assess an individual’s need for further intervention by
trained mental health staff and this was the purpose of the nurse’s
referral.
33. During the meeting with the investigator and the Family Liaison Officer,
the man’s wife said that a friend had gone to visit her husband the day
that he was admitted to healthcare. The friend was informed that he was
unwell and therefore would not attend the visit. The man’s wife had also
visited around the same time and told a female member of staff of her
anxiety. She was concerned that her husband had visibly declined in
both appearance and mentally. She was desperate for someone to help
13
him, particularly given the history of suicide and mental health issues in
his family. The man’s wife said that the person to whom she had spoken
made a note of her concerns but she was unaware of any other action
being taken as a result. The investigator made enquiries to try to identify
the member of staff, but no recorded information could be found and no
one was identified amongst the visit centre staff.
34. On 26 August, the day after the man was admitted to the healthcare
centre, a Doctor assessed him and recorded in his medical record:
“… Feeling flat and drained for 3-4 weeks. Suicide of sister
and worried about his family. No thoughts of self-harm. Used
Cocaine for many years at weekends. History of depression in
family. Does not wish to take offered anti-depressants.
Prescribed Zopiclone 7.5mg at
night …”
35. The information supplied by Staff A following the draft report also notes a
telephone call that he received from the man’s wife on 27 August:
“… Call from the man’s, wife. They heard he had been moved
to healthcare wing and were worried about him. I also had calls
from the man’s mother and from a cousin or aunt. Said that I
would telephone his wife and ask her to pass information on.
They told me that the man’s mum is having a breakdown and
that they had called a doctor out to see her this afternoon, but
not to tell him, as it would make him worse.
Went to healthcare, as they did not return my call. Would not
comment but told me to see him. The man cried as soon as I
said something kind. He said to tell his family he was low and
that he loved them. I telephoned the man’s wife and asked her
to talk to the rest of the family, which she said she would do. I
told her what he had said and that he was in tears. The man’s
wife said that her husband had never asked for help before. He
has children of 17, 16 and 9. I suggested she look up ‘Rethink’
website for them and that the family contact the carers centre. I
said that I would not telephone the man’s mother as she is in a
bad way …”
36. Nurse A, a mental health trained nurse, conducted a mental health
assessment with the man on 30 August, five days after his admission. It
is unclear whether this assessment was as a result of the man’s
admission to healthcare or the call made to Staff A on 24 August. As
part of his assessment, Nurse A recorded the following about the man’s
mood:
” … Coming to prison was a shock to him as first time in prison.
His low mood started on the wing whenever he thinks about
being in prison and being the ‘bread winner’. Most significantly,
14
he misses his children a lot because he is very close to them.
He described his mood as terrible before coming to healthcare
setting, loss of energy and feeling run down. Everything
appears gloomy and hopeless. He tries to avoid mixing with
other prisoners because he prefers to be on his own and
reminisce …”
Following the discussion about the man’s perception of his problems,
Nurse A questioned him in more detail and recorded the following:
“ … His mood has no underlying diurnal variation, neither being
worse in the morning nor improving as the day goes on, and
remains the same. Guilt: Feels that he let the family down
especially his children and as the breadwinner. Suicide: Has no
suicide ideation and never made any attempt in the past.
Fatigability: Loss of energy and being easily tired. Insomnia:
Unable to sleep but having had zopiclone for 3 nights appears to
have restored his sleep pattern. Anorexia: Loss of appetite to
begin with but now regaining it back. Thought disorder: No
evidence of any form of thought disorder, no evidence of any
form of hallucinations, hostility or suspiciousness …”
Nurse A concluded:
“ … The man has been suffering from reactive depression as
first time in prison, guilt (breadwinner) and missing his children.
States coming to healthcare setting gave him a break and
relaxing atmosphere and he is ready to be moved onto normal
location. He declined to take any form of anti-depressant
medication when first suggested by the doctor …”
37. At interview, the investigator asked Nurse A whether he considered
opening an Assessment, Care in Custody and Teamwork (ACCT)
document, given the man’s response, particularly as he made reference
to being hopeless and gloomy. (Any member of staff working in a prison
who has concerns about the welfare of a prisoner can open ACCT
documents.)
38. The information from Staff A was not available to the investigator when
he interviewed Nurse A, but Nurse A did not indicate that he was aware
of the concerns that had been raised by the man’s family. There is also
nothing documented in the man’s medical notes regarding the
information passed to the healthcare team by Staff A.
39. Nurse A said that he had discussed with the man any thoughts of self-
harm and he had no concerns that would require the opening of an
ACCT. The investigator asked Nurse A whether the factors such as first
time in prison, feelings of guilt and missing his children would have
increased the man’s level of risk of self-harm. Nurse A confirmed this
and said that an assessment would normally lead to a review by a
15
doctor. The doctor and nurse would jointly decide on appropriate
treatment. He added that, if the man had required additional monitoring
at that time he would have opened an ACCT document. The
investigation found no evidence that the review process described by
Nurse A took place in relation to the man.
40. Staff on A wing told the investigator that, when the man returned to his
wing on 1 September, it was like having “the old man back”. He had
mentioned that the time spent in healthcare had been useful. His job on
the landing had been kept for him although he was located a different
cell. This reportedly caused no problem for him. He was sharing a cell
with another prisoner with whom he appeared to get on well. The man
went about his daily work in his usual efficient way and staff had no
cause for concern. He continued to telephone his family regularly.
During the investigation, the investigator had access to the recordings of
these calls and it was apparent that the man was missing his family.
The man’s wife told the investigator and the Family Liaison Officer that
her husband was a very difficult person to read and good at hiding his
feelings.
41. The prisoner with whom the man shared a cell was released towards the
end of September. Staff told the investigator that, as he was out of his
cell most of the day, they did not want to place a newly arrived prisoner
with him and asked if he would rather remain on his own. This would
have changed if the prison had a large intake of new prisoners but at this
time numbers were reportedly quite low. The man told staff that he
would appreciate some time to himself.
42. On 24 September, the man was unlocked from his cell as usual and
spent the day cleaning. Staff said he appeared to be his usual self and
raised no concerns. That evening, it is likely that he and the other
cleaners were unlocked from their cells for a period of association.
(Association is the time when prisoners are allowed out of their cells to
socialise, make telephone calls or shower.) If so, he would have been
locked up at 7.00pm and a roll check, to count the number of prisoners,
would have taken place. However, the investigator could not confirm
whether the cleaners had association that evening as no regular
members of landing staff were on duty at that time.
43. During the night of 24 September, Operational Support Grade (OSG) A
was on duty on A wing. OSG A has worked at Bristol for around 12
years and been permanently on night duties for the last year. At
interview, OSG A explained that when he arrived for duty it was normal
for him to be given a handover from the day staff before he started to
check all the cells. The investigator asked OSG A whether he checked
that all cells were secure and also counted the prisoners. OSG A replied
that this was not necessary as the day staff would have already counted
the prisoners at 7.30pm and reported the numbers to the control room.
16
44. OSG A confirmed that he had no reason to go to the man’s cell during
the night. At around 5.30am on 25 September, OSG A conducted the
next routine roll check, checking each cell and confirming that the correct
number of prisoners were in each. OSG A reported his numbers to the
control room and confirmed no problems on the wing. The investigator
asked OSG A whether he could recall checking the man’s cell, and he
said that he had no recollection of it in particular. OSG A explained that
his aim when conducting a roll check is to ensure that the correct
number of prisoners are in each cell.
45. OSG A finished duty at around 7.30am when he was relieved by the day
staff. In response to a question by the investigator, he said that the
check he carried out and reported at 6.00am is the only roll check during
the morning. The day staff also confirmed that they are not required to
conduct a roll check when they start duty.
46. Officers A and B both arrived for duty on A wing at 7.30am on 25
September. After attending the morning briefing with other staff, they
went to the fours landing. Each officer went down one side of the
landing, unlocking all the cells. Officer A unlocked the side where the
man’s cell was located at around 8.15am.
47. The investigator asked Officer B to explain the procedure he followed
when opening a cell door. Officer B explained:
”I’ll open up the observation hatch, which is the small window on
the outside of the door, to make sure that there is no one waiting
at the door. I did this, and with the man’s cell, it did appear that
he was in bed at the time. I said good morning, which I do to
every cell, and then carried on to the end of the landing.”
48. In response to the draft report, the man’s family asked what level of
response is required from a prisoner when staff unlock their cells.
Officers will normally check the cell via the observation panel before
opening the door and then open the door, but not so that it is fully open.
Staff try to ensure that a prisoner’s dignity is maintained and when
unlocking in the morning some prisoners may be undressed. However,
staff are not required to obtain a response from every prisoner unless
they have specific concerns about an individual or the individual is
subject to self-harm or other monitoring procedures.
49. Officer B said that as the man was a trusted prisoner and landing
cleaner, it was not unusual that he would still be in bed so he would not
go into the cell to tell him to get up. After unlocking the cells, Officers A
and B returned to the end of the landing and began collecting
applications from prisoners. (Applications are written requests for an
item or service.)
50. A fellow prisoner (Prisoner A) and cleaner on A4 landing, made a
statement to the police after the man’s death. The investigator also
17
spoke briefly with him during his initial visit to Bristol. In his police
statement, Prisoner A said that he had shared a cell with the man. He
said that they had been close and discussed meeting up when they were
released. They continued to share the cell until the man was admitted to
the healthcare wing. Prisoner A says that when the man returned to the
wing he appeared to be back to “his old self” and life on the wing
continued as normal.
51. On 22 September, the man’s cell mate was released. Prisoner A said
that the man did not mention any concern about being in a cell on his
own. In fact, he had commented that he was looking forward to “having
his own space”. Prisoner A said that their routine was well established.
The man would go to his cell in the morning to make sure that he was
out of bed and they would have a drink before starting their cleaning
tasks.
52. On the morning of 25 September, Prisoner A said that things were
different as the man did not go to his cell. He walked past the man’s cell
and looked in. He could not see him, assumed that he had gone for a
shower, and did not go into the cell. A short while later, other prisoners
asked about him so Prisoner A went to his cell again. He could see the
man’s shoes on the floor and said that the bed looked as though
someone was under the covers. The lights in the cell were off and the
room was still quite dark. Prisoner A noticed what appeared to be a foot
sticking out from behind the end of the bed and walked into the cell. As
he walked to the back of the cell, Prisoner A saw the man hanging from
the end of the bunk. He immediately ran from the cell and called to
Officer A.
53. Officer A told the investigator that he was at the showers when he heard
a prisoner call him and, although he was not immediately aware of what
had happened, he could tell from the urgency that there was a problem.
He ran to the man’s cell and said that when he first looked in he could
not see any problem. As Officer A took a few steps into the cell, he saw
the man at the end of the bed in a seated position with a ligature around
his neck. He immediately called for Officer B to assist him. He tried to
lift the man and cut the ligature using his anti-ligature knife. (All prison
staff are issued with an anti-ligature knife, which they are required to
carry at all times.) Officer A said that, at this point, he did not know
whether the man was alive and his priority was to remove the ligature.
54. Officer B assisted Officer A and between them they checked the man’s
pulse and for any signs of life. Both officers told the investigator that it
quickly became apparent that the man had been dead for sometime and
that CPR would not be of any benefit. Officer B left the cell and called
down to the senior officer on the wing to alert him to the problem. Officer
B confirmed to the investigator that neither he nor Officer B were
carrying radios and that they were not designated a radio call sign.
Officer C, who had been alerted by a prisoner shouting to him, also went
to the cell at 8.45am. On seeing Officer A in some distress, he advised
18
him to leave the cell. Officer C also checked the man for any signs of life
and found that his body appeared to be stiff. Two Senior Officer’s
quickly joined him. The Orderly Officer in charge of the prison also went
into the cell.
55. Other staff alerted by Officer C via his radio, including healthcare staff,
arrived on the landing. A Nurse entered the cell at 8.54am, and again
checked for signs of life, but none could be found. At 8.58am, the prison
doctor, Doctor A, attended the cell and confirmed that the man had died.
The Orderly Officer had requested an ambulance and when the
paramedics arrived, they were informed that Doctor A had confirmed that
the man was dead.
56. When interviewed, Officers A and B said that the man had moved his
locker to a position that hid him from the view of anyone looking into the
cell from the doorway. He had also placed a blanket over the end of the
bed and another in the bed to give the impression that someone was
under the covers.
57. The cell was closed and sealed to await the arrival of the local police.
The police arrived at 10.30am and searched the man’s cell. No
apparent suicide note was discovered and the police identified nothing to
indicate that anybody else had been involved in the man’s death. The
police removed a number of items to be used as evidence from the cell,
including the ligature. A photograph of this was given to the investigator
and shows it to be intricate in nature, made up of torn bedding woven
together to produce a thick rope.
58. A Governor was appointed as the prison’s family liaison officer to
communicate with the man’s next of kin. The Governor told the
investigator that it was also brought to his attention that the man’s
partner was due to visit that afternoon, therefore priority was given to
visiting her home before she left for the visit.
59. The Governor and his colleague, visited the address given, but the
man’s partner was not at home and they were unable to contact her by
telephone. They then visited the man’s wife where they informed both
her and the man’s father of his death. The Governor spoke with the
family about what would happen next and what help and support was
available to them. This included information about the independent
organisation, INQUEST, which provides support and advice to families
bereaved following a death in custody.
60. The Governor maintained regular contact with the family. The prison
contributed to funeral costs and the prison chaplain officiated at the
man’s funeral. At the request of the family, no other prison staff
attended the funeral. Letters of condolence were also received by the
family from prisoners who had known the man, for which they were
grateful.
19
61. Staff at Bristol told the investigator that they had been appropriately
supported following the man’s death and that a debrief had been
conducted to highlight any immediate concerns.
20
ISSUES
Assessment, Care in Custody and Teamwork (ACCT)
62. Officer A was concerned about the man after they spoke on 25 August.
He contacted healthcare staff and documented his concerns in the
man’s wing history file so that other staff could be aware. He wrote that,
if the man deteriorated further, consideration should be given to opening
an ACCT. However, he told the investigator that he did not feel such
monitoring was required at that time.
63. The nurse who assessed the man documented his past family history of
both suicide and depression. She decided that it would be beneficial for
him to spend time on the healthcare wing. There is no mention of ACCT
being considered at this time. Nurse A conducted a mental health
assessment, but this did not take place until five days after the man had
been admitted. During the assessment, he talked about feeling
“gloomy” and “hopeless” and said that he felt as though he had let his
family down. However, he denied any feelings of suicide and the nurse
did not consider there to be a need for an ACCT to be opened.
64. Following the additional information supplied to the investigator, it is now
clear that the prison were made aware of the family’s concerns about the
man. Staff A passed the information to the Mental Health team and he
was told that an assessment would be carried out. We have been
unable to establish whether the assessment that followed was because
of this information or the fact that the man had been admitted to
healthcare. Regardless of what triggered the assessment, when it was
carried out Nurse A appeared to be unaware of the concerns raised by
the family or the comments made to the nurse about previous family
history. Had these factors been properly shared and documented, they
would have added to the bigger picture and enabled a more informed
decision to be made on the necessity to place the man on ACCT
monitoring.
65. The decision to implement ACCT monitoring requires staff to exercise
their judgement, taking account of the prisoner’s appearance, responses
and potential triggers. In this instance, neither member of staff
considered that the man warranted such monitoring, but they were
sufficiently concerned to take steps to obtain a mental health
assessment and healthcare supervision. Based on the subsequent
knowledge about the family’s concerns and the man’s disclosure of a
family history of suicide, there was enough evidence to warrant serious
consideration of opening an ACCT document. However, this did not
happen due to an apparent breakdown of communication between those
responsible for the man’s care.
66. The clinical reviewer, makes reference to both ACCT and the mental
health assessment:
21
“… I am of the opinion if an individual presents in such a setting
with symptoms of an acute onset moderate/severe depression,
that a Mental Health Assessment should be achieved within 24-
48 hours once the need has been identified, and that an ACCT
should be initiated, irrespective of the patients declared lack of
suicidal ideation or self-harm intent …
“… I am of the opinion that a Mental Health Assessment, once
the need was considered, based on concerns about depression
would have been achieved more expeditiously in the wider
community than that achieved in the prison …”
67. As a result of the investigation and those concerns highlighted by the
Clinical Reviewer, I make the following recommendation:
I recommend that the Governor issues a Notice to Staff reminding
them of the importance of opening an ACCT document when there
are serious concerns about a prisoner’s welfare.
The Head of Healthcare must ensure that when a prisoner requires
a mental health assessment it is carried out within 48 hours and,
where this is not possible, the reasons are clearly documented.
68. The man’s family expressed concern that, although a mental health
assessment had been conducted, staff had not contacted them for
further background information on his history. They considered that they
would have been in a position to share their concerns about his
deterioration in the previous weeks and that this may have been
beneficial in deciding on his care. The ACCT procedure allows family
members to be involved in the care planning process if the prisoner
gives their permission. This input might have been helpful but would
only be possible had ACCT been in place.
69. Nurse A confirmed that the man’s description of his feelings would
normally have raised concerns about his wellbeing and should have
triggered a review by a doctor. There is no indication that this happened
in the man’s case despite the negative feelings that he expressed.
According to his family, he tended to hide his feelings so it is possible
that no action would have been taken even if he had seen a GP.
However, if this is an agreed process it should be followed.
The Head of Healthcare should ensure that when mental health
assessments are conducted an immediate follow up with a doctor
is carried out and the results are documented.
70. OSG A told the investigator that he had not had ACCT training since
taking up his role conducting night patrol. Given that staff working at
night can do so in isolation and have responsibility for the monitoring of
prisoners in their care on open ACCTs, it is essential that they are
22
provided with appropriate training. The investigator was told that OSG A
was due to have ACCT training in the next few months.
The Governor should ensure that all staff who have direct contact
with prisoners have appropriate ACCT training and that all
permanent night staff undergo the foundation training in ACCT
procedures.
71. ACCT documents cannot guarantee prevention of self-harm or suicide,
but the process gives additional support and highlights to staff the need
for the individual to be watched more closely. The lengths that the man
went to, firstly to make a ligature that appeared to have taken sometime
and then to conceal his actions suggest to me that an open ACCT is
unlikely to have prevented his death. The family have said in response
to the draft report that they feel that if the man had been on an ACCT
then he would not have been placed in a single cell and this would have
prevented or at least made it difficult for him to self-harm.
72. I agree that sharing a cell with another prisoner would have made it
harder for the man to self-harm without being discovered. However, I
cannot assume that this would have been sufficient to prevent the man
taking his life, as unfortunately self-inflicted deaths of prisoners in shared
cells do occur. The family have also commented that guidance set out in
the Prison Service Order (PSO) 2700 on Suicide and Self Harm provides
staff with advice on placing those prisoners considered ‘at risk’ in single
occupancy cells. I cannot comment on this as ACCT procedures were
not in place for the man, therefore this guidance was not applicable
when the decision to allow the man a single cell was made.
Roll checks
73. During the investigation, it became apparent that the profiled roll checks
at Bristol do not require staff taking over a shift to confirm the roll already
submitted by outgoing staff. This system is now common across the
Prison Service. OSG A had carried out the last roll check at 5.30am and
saw nothing that gave cause for concern as he had seen what he
believed to be somebody in the bed. When Officer B unlocked the cells
at 8.15am, he made a point of looking into the cell, but he also saw what
he believed to have been someone in the bed. Following the man’s
death, the roll check procedures at Bristol were reviewed but I have not
been advised of the results of the review.
74. The description by staff, as well as information from the police following
the man’s death, would indicate that he had died several hours before he
was eventually discovered. I do not believe that a roll check at 7.30am
would have made a difference in this case. However, the forms for
recording roll checks at Bristol still indicated that a roll is to be taken at
7.30am even though this no longer happens. This document should be
amended to avoid confusion.
23
The Governor should review the wing daily diaries and amend the
roll check times indicated to show only those that are actually to be
carried out.
Provision for families to raise concerns
75. When the man’s wife first raised concerns about her husband during a
visit, she said that the officer told her nothing could be done unless a
prisoner directly asked for help. The family were concerned about this
and, although a member of staff eventually approached him in the visits
room, they felt that in such an environment he was unlikely to disclose
anything that was bothering him. It is important that concerns raised by
prisoners’ families are taken seriously. They should have been
documented and passed to the man’s wing staff so that they could be
followed up or monitored.
I recommend that the Governor issues a Notice to Staff setting out
the correct procedures to be followed when a member of staff
receives concerns from a prisoner’s family.
76. The man’s father said that his ex-wife had telephoned the prison about
her concerns and had left a message. However, they had received no
response. The investigator asked the prison about their arrangements
for families to telephone with concerns. He was told that a helpline is in
place and the number and instructions for its use are advertised in the
visits centre and visits room. In addition, all visiting applications sent out
to visitors contain information about the helpline. The helpline is
checked daily, responses made to all calls and, where necessary,
followed up by the prison’s safer custody team. The investigator was
given copies of the documents advertising the helpline and these are
attached as annexes to this report. In addition, he was also provided
with a copy of all calls received to the helpline during the man’s period in
custody. No calls relating to him are shown. I am unable to explain the
discrepancy between the family’s account and the prison records. It is
unfortunate that wing staff seem to have been unaware of the family’s
anxieties and so did not recognise that the man might be withholding any
worries.
77. The new information supplied to the investigator by both the family and
the prison following the draft report, confirms that the family had raised
concerns with the prison. The initial reason that the prison were unable
to identify the calls was the belief that the family had contacted the Safer
Custody Helpline. In fact, the calls had been made to the Prison Advice
and Care Trust (PACT) located in the visitor’s centre. Staff A from PACT
had taken the calls and followed these up by speaking with the Mental
Health team and also with the man himself.
24
78. While the follow up actions by Staff A were wholly appropriate, I am
somewhat concerned about the confusion that could be caused to
families where two helplines are advertised. The man’s family believed
that they were calling a helpline specifically for raising concerns about a
prisoner’s welfare. There is also no evidence that the concerns raised
by the family were shared by Staff A with anyone else such as wing staff
or the safer custody team. In view of this I make the additional
recommendations:
The Governor should liaise with the Prison Advice and Care Trust
to ensure that the leaflets they provide to prisoner’s families
includes the safer custody hotline number.
The Governor should liaise with the Prison Advice and Care Trust
to agree the procedures to be followed when concerns are received
by them about the welfare of an individual prisoner.
25
CONCLUSION
79. Although this was the man’s first time in prison, he appeared to settle in
quickly. He had a job in which he took great pride and got on well with
both staff and other prisoners. He was a mature man who was
considered ideal to speak with new prisoners and help them with any
concerns.
80. He was described as a private man who chose not to discuss his
personal life in too much depth. His family described him as “difficult to
read”. His fears about what would happen to him at court were clearly of
great concern. He believed that the charges against him would result in
a lengthy period in custody and he would lose all that he had worked
hard for. Despite his family’s reassurance that this was unlikely, he
continued to feel that things were hopeless. During his mental health
assessment, he spoke of letting his family down and feeling gloomy and
hopeless. Although offered, he declined anti-depressant medication.
The circumstances suggest that monitoring under the ACCT process
should have been considered, and these views are strengthened by the
information that has been shared since the issue of the draft report.
81. I believe that the man was capable of masking his true feelings in the
presence of wing staff and his friends in prison. However, in telephone
calls to his family he was still clearly upset and feeling that he would
never get out of prison. The ligature that the man used can be described
as intricate and would have taken some time to make. It is clear from
this alone that he had been considering harming himself for sometime.
That said he went to great lengths to portray to those he saw daily that
he was coping. It is not clear why the man chose to take his own life, but
the belief that he was not going to get out of prison and that he had let
his family down are likely to have influenced his decision.
82. In response to the draft report, the National Offender Management
Service (NOMS) said that they had no comments at that time and would
reserve comment until the concerns raised by the man’s family had been
added to my report. However, a response to the initial recommendations
was provided and is detailed below.
26
RECOMMENDATIONS
1. I recommend that the Governor issues a Notice to Staff reminding them
of the importance of opening an ACCT document when there are serious
concerns about a prisoner’s welfare.
The Prison Service accepted this recommendation and a Notice to Staff
was issued on 3 March 2010.
2. The Head of Healthcare must ensure that when a prisoner requires a
mental health assessment it is carried out within 48 hours and, where
this is not possible, the reasons are clearly documented.
The Healthcare partially accepted this recommendation and said:
In the most serious of cases, assessments will be conducted within
48hours by a RMN and will be seen by a doctor.
We cannot generalise all mental health assessments into this time scale
from the wing due to resource implications and therefore, it would not be
appropriate to undertake all of these assessments within this time frame.
This is as per Avon and Wiltshire Partnership policy
3. The Head of Healthcare should ensure that when mental health
assessments are conducted an immediate follow up with a doctor is
carried out and the results are documented.
The Healthcare partially accepted this recommendation and said:
Not all mental health assessments will need to be seen by a doctor
however, in the most serous of cases this will occur in conjunction with
the RMN.
This is as per Avon and Wiltshire Partnership policy
4. The Governor should ensure that all staff who have direct contact with
prisoners have appropriate ACCT training and that all permanent night
staff undergo the foundation training in ACCT procedures.
The Prison Service accepted this recommendation and said:
‘… There is currently a continuous training package delivered by
Training to ensure all staff are up to date with ACCT Foundation. 90% of
all staff have been trained and 100% of all night staff have been trained
…’
5. The Governor should review the wing daily diaries and amend the roll
check times indicated to show only those that are actually to be carried
out.
27
The Prison Service accepted this recommendation and new diaries have
been ordered and a Notice to Staff issued on 10 March 2010.
6. I recommend that the Governor issues a Notice to Staff setting out the
correct procedures to be followed when a member of staff receives
concerns from a prisoner’s family.
The Prison Service accepted this recommendation and a Notice to Staff
was issued on 3 March 2010.
7. The Governor should liaise with the Prison Advice and Care Trust
to ensure that the leaflets they provide to prisoner’s families
includes the safer custody hotline number.
8. The Governor should liaise with the Prison Advice and Care Trust
to agree the procedures to be followed when concerns are received
by them about the welfare of an individual prisoner.
28