Individual at Winchester

Investigation into the circumstances surrounding the
death of a man
at HMP Winchester in July 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2009
This is the report of an investigation into the circumstances of the death of a man in
July 2008. At just before 9.00am, he was found hanging in his cell at HMP
Winchester. Cardio pulmonary resuscitation (CPR) was carried out but he was
pronounced dead at 9.14am. He was 27 years old and had been in custody for ten
weeks. It was his first time in prison and he was facing a very serious charge. He
was from Bangladesh, in Britain on a student visa and could speak and write English
fluently. He left two hand written documents of significance in his cell.
I would like to offer this public expression of sympathy and condolences to the man’s
family and friends for their loss. A key objective of all the Ombudsman’s
investigations is to ensure that the bereaved family has the opportunity to raise any
concerns and contribute to my enquiries. His family raised a number of concerns
with one of the family liaison officers and with the investigator. I hope this report
offers answers to their questions and I regret the delay in its completion.
The investigation was carried out by my colleague. A clinical review was conducted
by a clinical reviewer for the local Primary Care Trust, and I am very grateful for his
report. I would also like to thank staff at HMP Winchester for their assistance.
At HMP Winchester, the man appears to have been ‘invisible’. Not one of the staff
interviewed knew anything about him. The only evidence about him has been
provided in a statement by his cellmate. No staff at Winchester could recall him and
the mechanisms which should have been in place to support him – the Personal
Officer scheme and the Foreign National policy – failed him. Indeed, the prison was
unable to even identify who his personal officer should have been. Also, in spite of
being appropriately identified upon reception as a foreign national, he did not have
any contact with those responsible. He did not make any telephone calls or arrange
any visits. Whilst it is not possible to say whether more contact with staff would have
made a difference to his state of mind, this report is a disappointing account about
the care offered prisoners in HMP Winchester.
My report reveals failings in the Personal Officer scheme and the process of dealing
with Foreign National prisoners, and contains four recommendations.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman November 2009
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CONTENTS
Summary
The Investigation Process
HMP Winchester
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was arrested on 14 May 2008 for murder and held in police custody for five
days. During this time, and because of the nature of the offence, he was assessed
by a Forensic Medical Officer (FME) but was not deemed to be at risk of suicide or
harm to himself.
He appeared at Magistrates Court on 19 May and was remanded to HMP
Bullingdon. He was placed overnight in the healthcare centre in accordance with
Bullingdon’s policy regarding those charged with those charged with murder. He
was also referred for a mental health assessment. He saw the prison doctor the
following morning who did not detect any mental health problems or suicide risk. He
was deemed fit for ordinary location and transferred that afternoon to the main
prison. He had been correctly identified as a foreign national.
On 30 May, the man appeared at Crown Court and was remanded to HMP
Winchester. A further health screen was carried out and no concerns were raised.
He was not referred for an urgent mental health screen despite Winchester’s policy.
Again, he was identified as a foreign national. Rather than being located onto A
wing, the induction wing, he went into the main prison, B wing. (No more qualitative
information about him was documented by staff from then on.)
On 2 June, his cell mate moved into the cell with him and they continued to share a
cell until 28 July. He was described by the cellmate as being ‘a bit odd’ and he did
not socialise with anyone else on the wing.
Seven weeks later, on 25 July, the man saw his solicitor who did not have any
concerns about him. Over the weekend, his cell mate described a deteriorating
relationship between them. On Monday, 28 July, the cell mate left the cell early in
the morning to go to court. At approximately 9.00am, the man was found hanging
when staff went to unlock his cell so that he could go for exercise. CPR was
performed but, sadly, he was pronounced dead at 9.14am.
Four recommendations have been made in response to the serious failings of what
should be established processes, including two about the Personal Officer scheme
and the Foreign National Policy.
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THE INVESTIGATION PROCESS
1. One of my colleagues conducted a preliminary visit to HMP Winchester on 5
August on behalf of the investigator responsible for the investigation. She met
the Governor and collected all the relevant documentation. At a later date,
the investigator met a representative from the Independent Monitoring Board.
Feedback was provided as the investigation went on and she met again with
the Governor during the investigation.
2. Notices were issued to staff and prisoners telling them of the investigation and
offering the opportunity to speak with the investigator. No one came forward
as a result. Ten interviews were recorded with members of staff.
3. The clinical reviewer for the local Primary Care Trust undertook a clinical
review of the healthcare provided for the man whilst at HMP Winchester.
Four medical staff were interviewed jointly with the investigator.
4. The investigator made contact with the police officers responsible for
investigating the man’s death and those investigating his alleged offence.
The cellmate, who was released on the morning of the man’s death, was
interviewed by police and a copy of his statement was shared with the
investigator. The investigator wrote to the cellmate at the address provided
by the prison asking him to contact her but he did not do so. She
subsequently asked the police to help contact him and was provided with a
mobile telephone number. Again, attempts to reach him by mobile were not
successful.
5. HMP Bullingdon was contacted by the investigator and she spoke on the
telephone with the Operations Lead in Healthcare to obtain information about
the man’s time there and the notes from this conversation are annexed.
6. In addition, the investigator telephoned the man’s solicitor to obtain
background information and to discuss the visit which took place three days
before his death.
7. One of the family liaison officers and the investigator met the man’s family.
The purpose of the meeting was to listen to their concerns about the
circumstances surrounding his death. His sister said she tried vigorously to
contact her brother, both via letters and telephoning the prison, but was
unsuccessful. Being both unfamiliar with prisons, and with limited English,
she found it difficult to navigate her way through the system.
8. A copy of the draft report was sent to the Prison Service. They reported that
there were no factual errors and accepted all the recommendations. The
responses to the recommendations are repeated verbatim in the relevant
section.
9. A copy of the draft report was translated into Bengali for the man’s next of kin,
his sister. Also, my family liaison officer and the investigator, in the company
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of an interpreter, visited the man’s sister to answer any questions in response
to the draft. No changes to the report were requested.
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HMP WINCHESTER
10. HMP Winchester is a category B local prison built in 1846 to a Victorian radial
design. Winchester is currently undergoing major refurbishment with a build
programme lasting five years. Work which has already been completed
includes safer custody changes to the healthcare centre, first night centre and
detoxification unit, a new electrical system, renewal of the fire and general
alarms, a new visits complex and pedestrian access at the main gate.
11. Prior to the man’s death there were nine deaths at Winchester since the
Ombudsman began investigating deaths in prison custody in 2004. Seven
were a result of natural causes, and two were apparently self-inflicted.
12. The Independent Monitoring Report of 2007/2008 concluded:
“HMP Winchester performs well for a local prison under tight financial
constraints. This is due to a highly committed team, both management
and staff. The closure of C Wing has made the segregation of different
groups of prisoners difficult at times. The constant churn of prisoners
and the lack of funding for courses continue to provide problems.”
13. HM Chief Inspector of Prisons last inspected Winchester in April 2007. She
published her report in June 2007 and commented:
“Like all local prisons it faces considerable pressures and increased
demands. There was some evidence, at this inspection, that this
combination was testing the prison’s ability to sustain and continue
improvements. Winchester remains a reasonably well performing local
prison, in spite of the pressures in the prison system as a whole.
However, there are some warning signs – the lack of sufficient activity
spaces in the main prison, the somewhat dislocated resettlement
places and, in particular, the fact that residential staff are not fully
engaged in the support and rehabilitation of prisoners. These are all
matters that prison managers, and the National Offender Management
Service, will need to monitor closely.”
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KEY FINDINGS
14. The man was arrested in London on 14 May 2008. He was taken to a police
station for questioning and during this time was seen by a Forensic Medical
Examiner (FME) who deemed him for fit for interview. He remained in police
custody for five days, during which time there were no concerns about suicide
or self-harm.
15. He appeared at Magistrates Court on 19 May and was remanded to HMP
Bullingdon. His Prisoner Escort Record (the key instrument for ensuring that
information about risk is shared between agencies) stated that he had no
known risks. Upon his reception at Bullingdon at 4.50pm, he went through the
usual procedures which included completing the Core Record. When asked
to identify his next of kin, the author wrote ‘none’. He described his
occupation as a waiter, his place of birth as Bangladesh and said that he was
a Muslim.
16. The Cell Sharing Risk Assessment (CSRA) described him as a low risk for
sharing a cell, noting that it was his first time in prison and that the author had
no concerns about the man. Part three of the CSRA was completed by a
nurse who ticked that she had no concerns about self-harm.
17. The nurse also carried out the First Reception Health Screen (FRHS).
(Bullingdon has a computer medical system so responses to questions are
entered onto the computer by the nurse at the time of the interview.) The man
was not identified as having any physical or mental health problems. He was,
however, admitted to healthcare for the night because of the severity of his
offence. He was also referred for a mental health assessment. The
Operations Lead in Healthcare said in a telephone interview that the
procedure at Bullingdon is for the prisoner to be seen the following day by
medical staff who assess whether someone needs to be referred for a mental
health assessment.
18. An entry at 8.06pm, in the man’s medical record said,
‘in-patient admission due to the severity of offence – searched and
located into H118 quite demanding since being located – asking
continuously about extra food despite having a meal in reception – regime
explained and advised against inappropriate use of cell bell’.
The following morning, 20 May, the daily nursing comment noted ‘quiet and
settled overnight’.
19. A General Practitioner wrote at 11.36am,
‘Denies any medical or mental health problems. 1st time in prison. No
thoughts of dsh [deliberate self-harm]. Denies drug or alcohol use. No
concerns from staff. Fit for o/l [ordinary location].’
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Consequently, the man was not referred for a mental health assessment.
Later that afternoon, he transferred to the Blackthorn Unit and located into cell
B3-08.
20. A Reception Board document was completed on 20 May. The man was
identified at this stage as a foreign national. However, this information was
not recorded on his record of events booklet (known as a history sheet).
(There are no more entries in any records at Bullingdon.)
21. On 30 May, the man appeared at Crown Court and was remanded to HMP
Winchester. His PER had marked violence as a risk with the additional
comment ‘main offence: murder, violence = main offence’. He arrived at HMP
Winchester at 12.20pm. His CSRA identified him as a medium risk to others
(that is no immediate risk, but the situation will need to be reviewed regularly)
with an additional comment ‘would prefer a single cell; states he gets angry
quickly’. A Health Care Officer (HCO) completed part three of the CSRA and
indicated that no concerns about self-harm had been raised. (A HCO is a
prison discipline officer who specialises in healthcare and is able to perform
some nursing duties such as first night health screens and looking after in-
patients.)
22. The HCO, who regularly worked in reception, completed a health screen;
again this involved entering information directly into the computer. In
interview, he was unable to recall the man or whether his medical record had
arrived with him. He carried out a full healthcare screen (indicated by the
detailed information about him) which, in interview, the HCO felt might
indicate that he did not have access to the previous records. Otherwise, he
said he would have done a limited screen. Amongst the comments recorded,
the HCO wrote -
‘General mental health. Has been to Crown Court today. Say he feels
alright.
‘Full history taken.
‘Past medical history states normally fit and well.
‘Remanded for murder.’
23. In interview, the HCO was asked whether he was aware of Winchester’s
Suicide Prevention and Self-Harm Management Policy and Strategy
Document which reads ‘to help manage the risk these prisoners present
(those charged with offences related to violence against a family member
and/or homicide), all prisoners that are charged with these offences will have
an urgent mental health referral submitted by the health-screener in
reception’. He responded,
‘not really, no, and really that should be done by the prison that he
goes to first anyway, things have changed a bit over the years so I
won’t relate to what we used to do, or how we used to do things, but as
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a matter of course people aren’t referred for a mental health
assessment if they are on a murder charge’.
24. Later that day, the man completed the first stage of his induction. He was
identified as a foreign national and it was noted that he could speak English
and read and write. However, this information was not recorded on any of his
other documents, including his history sheet. He only identified significant
problems with ‘close relationship with family members’ and ‘current
relationship with partner’. No other problems were identified. He was also
seen by the legal services team and no issues were identified. However, he
gave details of a different firm of solicitors (a London firm rather than the firm
representing him) when asked to identify his solicitors name and contact
details.
25. The man was located onto B wing, cell B3-07. (Winchester uses A wing as a
first night centre and it is the usual practice is for prisoners to go there first if
there is available space. A prisoner may spend as long as a week there as he
becomes familiar with prison life, especially if it is there first time in custody.)
However, for reasons unknown, he was located onto B wing. (His future cell
mate, who arrived at the same time as him, was located initially on A wing.)
On 31 May, an entry in his history booklet by one of the personal officers for
prisoners on the third floor landing, wrote ‘only just arrived on the wing too
early to make a proper entry’. (Every prisoner should be allocated a named
personal officer who is required to take a specific interest in them and
complete entries in their history booklet every 14 days. Personal officers are
allocated prisoners on a particular landing, rather than the same personal
officer remaining with a prisoner wherever they move within the prison.)
26. On 1 June, the man moved into cell B4 -13. There is no entry about this
move in the wing’s observation book or his history booklet and the reason is
unknown. Having moved to a different landing, his personal officer would
have changed. However, having wrongly interviewed the personal officer, the
investigator asked to interview the officer responsible for B4-13 but no one
could be identified.
27. The next day, 2 June, the man’s cell mate moved into the cell and remained
there with him until 28 July. The man went through a Stage 2 induction on 3
June, which is a group induction.
28. Three days later, he was seen by a second HCO for the second health screen
during which his weight, height and blood pressure were taken.
29. On 11 June, an entry in his history booklet says ‘SO check’, meaning that a
senior officer had checked the record. The following day, a scheduled CSRA
review was completed by a SO. This is a paper exercise and he was not
present. He was again identified as a medium of risk of harm to others as first
assessed on his CSRA when he arrived at Winchester. Under the section,
‘action required’, the SO has written ‘unknown quantity at the moment to be
monitored closely by wing staff’.
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30. The next entry in his history booklet was made on 1 July and reads ‘CSRA
Mgt check. Review due 12/9/08’, also referring to a check by a prison
manager. On 6 July, the SO wrote ‘wing SO check entries required every 14
days.’ Another management check was made two days later on 8 July,
‘CSRA Mgt check. Review due 12/9/08’. There are no further comments on
the man’s history booklet. (It is worth noting that his cell mate’s history
booklet is equally brief.) In interview, the Senior Officer (SO) said that he was
the senior officer with responsibility for the fourth floor landing and would have
expected to see a comment from the personal officer every 14 days.
31. In the statement provided to the police, the man’s solicitor said that he saw
him on 25 July and was with him for about an hour. There was some
disagreement between the solicitor and a legal visit officer about the amount
of legal documents he was allowed to hand over to him. In the end, a
compromise was reached and the solicitor was able to pass some, but not all,
of the case papers to him. He was going to send in the remainder of the
papers. The solicitor said that the man ‘did not appear any different in his
demeanour than in my other meetings with him’. He added that the man ‘did
provide instructions to me which due to client confidentiality and further from
advice that I have sought for the Law Society Ethics Advisory Department I do
not wish to disclose’.
32. The cell mate gave a very frank statement to the police in which he described
the deterioration in his relationship with the man over that last weekend
following the solicitor’s visit, and their previous contact. He said that they had
first met in the holding cell at Bullingdon. He described the man as ‘a bit odd.
He didn’t say a lot and was always staring like having tunnel vision’. At first
they did not speak much but neither of them liked football and so they had
that in common. He said that the man did not socialise with any other
prisoners on the wing. The cell mate said that the man told him why he was
there although repeatedly said that ‘I never done it’.
33. In his statement to the police, the cell mate said,
‘We must have shared a cell for about a week when the man first
mentioned suicide. I can recall him saying he wanted to kill himself
and that he did not want to spend the rest of his life in prison. I did not
think much about what he was saying because most people in prison
feel like this at some stage and it is just one of those things that you go
through. … I have also just remembered that about three weeks ago
when he was asleep I went through his unit as I did not have any clean
kit – T-shirt and thought I would take one of his. I can remember when
looking through his stuff I noticed a cord of sheets like a rope. I didn’t
think much of it and thought it was a rope used as a ‘swinger’ to swing
items from cell windows and that it had been left in the locker. I never
mentioned it to him and did not give it much thought until today.’
34. The cell mate said that the man confessed in June to the allegation of murder
and told him details of the events leading up to it. On 21 June, the cell mate
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wrote a letter to his own mother saying that the man had confessed and he
did not know what to do as he did not want to be a ‘grass’.
35. Following the visit from the man’s solicitor, the cell mate said that on Saturday
26 July he asked him if he could read the case papers he had been given. He
said that the papers did not support what the man had told him and said,
‘I did not feel the same about the man after reading this. I spoke to him
if he spoke to me but did not make conversation with him. Around
8.00pm on the Saturday the 26 July in the evening I can recall him
writing a long letter. I kept trying to read what he was writing in his
book but he kept covering it up. I can recall that we had a bit of an
argument because I wanted the cell lights off. At around midnight he
turned the lights back on and said to me ‘I need the lights on for ten
minutes’. After 10 minutes I wanted the light off and could see him
reading the statements in his deps (that is his deposition). I got up and
put the lights off and got annoyed with him and pushed him onto his
bed. The rest of the night was uneventful.
‘On Sunday 27 July 2008 nothing much happened. I did not speak to
him much. He spent most of the day writing in his book. … On Sunday
night I could not sleep because I was due in court the next day. I spent
all night with the telly on. I know he could not sleep as I could see him
on his bed and he kept clicking his fingers and tapping on the wall all
night. He would often do this but was doing it more and more in the
last couple of weeks.’
36. The morning roll check took place before prisoners were unlocked to be taken
to court. On Monday 28 July, an officer collected the cell mate between
7.15am and 7.30am. The officer recalled in interview that the man was in bed
and appeared to be asleep. In his statement, the cell mate said
‘On Monday 28 July 2008 I got up and got ready for going to court. He
was laid on his bunk and was clicking his fingers again which was
driving me mad. When the prison officers came to get me I got up and
jokingly said to him ‘see you later mate, enjoy your 20 years’. He did
not reply. I left the cell.’
37. The cell mate was released by the court and did not return to Winchester
prison that day.
38. As prisoners are given a breakfast pack when they are locked up for the night,
the first time that the remainder are unlocked is for exercise. An officer was
unlocking B wing for exercise. Usually this takes place at 8.30am but staff
shortages meant that it was delayed that day. At approximately 8.59am, he
reached B4-13 and called through the door asking if the prisoner wanted to go
for exercise. There was no reply and he opened the observation hatch to see
the man hanging from the window bars. The officer immediately unlocked the
door, calling to his colleague who was on the other side of the landing for
assistance. The second officer put out a Code One call (the call sign for a life
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threatening emergency) over his radio as he made his way across the
landing. The control room recorded that this call was made at 9.01am.
39. The first officer held the man’s weight whilst he also tried to cut the ligature
with his anti-ligature knife. He was unable to do so and, at this point the
second officer arrived and took the knife cutting the ligature. Initially the
officers placed him on the bed and then moved him onto the floor with the
help of another officer. The first officer blew his whistle and the third officer,
who had checked for a pulse but could not find one, began cardio pulmonary
resuscitation (CPR) with the second officer. The second officer was doing the
compressions and the third officer, using his face mask, started breaths at a
ratio of thirty to two. (The third officer is a first-aid instructor.)
40. A nurse arrived with the emergency bag and set up the ambu-bag (a hand-
held device used to provide positive pressure ventilation to a patient who is
not breathing or who is breathing inadequately) and oxygen. He and the
second officer rotated doing chest compressions. A second nurse also
responded to the Code One call and, according to the scene log, arrived at
the cell a minute later. She asked whether an ambulance had been called,
and discovering it had not, radioed the control to call for one. The control log
recorded the ambulance being called at 9.02am. She also asked for the
prison doctor to be redirected to B wing when he arrived at the prison gate for
his morning duties. She asked for the defibrillator to be collected which was
locked in the treatment room on C2 level. (In reality, this was very near by.)
The second nurse attached the defibrillator which indicated that CPR should
be continued.
41. The prison doctor was already in healthcare and went to the cell after being
told by a prison officer that he was needed. In interview, he said there was
little urgency about the request. He arrived at the cell at 9.11am and the man
was pronounced dead at 9.14am. The ambulance arrived at the prison at
9.20am.
42. The man had not given any details of his next of kin. However, the prison was
able to establish that his sister lived in Haringey. At 9.30am, the Head of
Residence, contacted HMP Pentonville (which was the nearest prison) to ask
a senior manager to go to the home of the man’s sister. The Deputy Head of
Prisoner Care at Pentonville contacted the man’s sister by telephone to say
that he would like to come and speak with her in person. He arrived at her
home 25 minutes later and broke the news. He gave the family contact
details for the duty governor and the Family Liaison Officer (FLO) at
Winchester. When he returned to Pentonville he asked their Imam to contact
the family as his sister requested.
43. On 31 July, the prison FLO drove to the family home to collect six members of
the man’s family and take them to the prison. It had been arranged that the
Imam from another prison would also be present. They were then taken to
view his body at the hospital. His parents live in Bangladesh and the family
wanted to have his body returned there. The prison helped to arrange this
and paid the cost of returning his body home.
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44. The police removed two ‘letters’ from the cell. One very short one began ‘I am
very sorry to her mum’ (referring to the victim). Unfortunately the man’s family
understood that the message was addressed to his own mother. Another
document of more than 37 pages was retrieved from the cell. The police did
not pass them to the family, and the Ombudsman’s investigator and family
liaison officer passed them over when they came into their possession.
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ISSUES
First reception health screen
45. The man went through the reception procedures when he arrived at HMP
Winchester. He had already spent time at HMP Bullingdon where it had been
thought that he did not need to be referred for a mental health assessment. It
is not clear whether these medical notes were available to the first HCO who
saw him in reception. However, he was not referred to the mental health
team in accordance with Winchester’s Suicide Prevention and Self-Harm
Management Policy and Strategy Document. It is an example of good
practice that prisoners charged with murder are automatically referred for a
mental health assessment. Neither the first HCO nor the HCO who
accompanied him at the interview, were familiar with the policy. Both staff
regularly carry out reception duties. They both referred to a previous policy
which required such prisoners to be placed in healthcare overnight, saying
that it had not been in existence for some time. Of the two nurses
interviewed, also responsible for reception duties, one said she was aware of
the policy and the other was not.
I recommend that the Governor and the Primary Care Trust ensure that
all healthcare staff are familiar with the relevant section of the Suicide
Prevention and Self-Harm Management Policy and Strategy Document.
Induction and Foreign Nationals
46. It is not known why the man was not located on the induction wing, A wing,
when he first arrived at Winchester. Furthermore, his alleged offence
generated a considerable amount of press coverage and it does not seem
that any consideration was given to how to manage him on the wing.
47. The man was appropriately identified as a foreign national at Bullingdon and
Winchester. In accordance with Winchester’s Foreign National Prisoner
Policy, this should have resulted in a number of things taking place,
‘As part of the Induction Programme, induction staff will ask every
prisoner what their nationality and first language and record this on the
Foreign National documentation and their history sheet.
‘All foreign national prisoners to be asked to complete the Foreign
National questionnaire during the first 48 hours.
‘The FNLO (Foreign National Liaison Officer) must see all foreign
national prisoners within 48 hours of notification of reception:-
a) to check on immediate needs and concerns
b) to deliver a copy of the Foreign National self-assessment
questionnaire and explain how it should be completed.’
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48. Although identified as a foreign national, the man’s history sheet was not
marked to indicate this. He does not seem to have been spoken to about any
immediate needs or concerns. The investigator was told that a Foreign
Nationals Liaison Officer was in post at the time although had left
subsequently and it is unclear how he came to be overlooked.
49. The ‘maintaining family ties’ section of the policy explains how a foreign
national prisoner is entitled to extra telephone calls if they have had no family
visits during the previous month. The policy does not say who will be
responsible for checking this. Although the man had family in this country, he
did not send out any visiting orders and did not make any telephone calls.
I recommend that the Governor ensures that the Foreign National
Prisoner Policy is implemented by all staff.
50. Neither the man’s history booklet, nor that of his cell mate, have any entries to
suggest that they were seen by their personal officer once they moved onto
B4-13. Neither record contains anything of substance about them as
individuals. When the investigator asked to speak with the man’s personal
officer, she was given the name of an officer responsible for him during his
first two days on B wing which is before he moved to another landing and
became the responsibility of the officers on that landing. The error was not
identified until the officer was interviewed. The investigator asked for the
correct personal officer to be identified but no one could be named.
51. An entry should be made in every prisoner’s history sheet at least every 14
days. There was a comment in the history document by a senior officer
reminding the personal officer to write an entry. This did not, however, prompt
any entries to be made. The system should be monitored in other ways, for
example, at the morning staff meeting and reminders in the wing observation
book. Indeed, given that the man’s personal officer could not even be
identified is of concern.
The Governor should ensure that the personal officer scheme is working
in accordance with policy and that senior officers monitor it robustly.
Response to the emergency
52. In his review, the clinical reviewer concluded that ‘the response to finding the
man was immediate and appropriate but, unfortunately, efforts to resuscitate
him were unsuccessful’. However, he goes on to comment that,
‘There should be a review of the emergency call system … the arrival
of the equipment and call for external help needs to be formalised. If a
‘code one’ is called, namely a life threatening emergency, one of the
nurse radio holders should be clear that they are ‘on call’ for such calls
at any particular time and must respond urgently, rather than relying on
all available personal to attend … as in hospital, it would seem
appropriate to allocate a specific member of staff to have responsibility
to collect emergency equipment and bring it to such emergencies.
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Similarly, protocols for calling for a 999 ambulance need formalising as
part of the set response to receiving such a confirmed call in the control
room.’
53. I note that the Ombudsman has made the same recommendation after an
earlier death at Winchester and, given the clinical reviewer’s comments, I am
disappointed to repeat it here.
The Governor and Head of Healthcare, in collaboration with the Primary
Care Trust, should review the emergency medical response system.
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CONCLUSION
54. The man did not have any significant contact with staff for the entire period he
was at Winchester. The Prison Service has well established systems to
identify and support vulnerable prisoners. Tragically none of the systems –
that is a mental health assessment, being located on the induction wing,
identified as a foreign national prisoner and regular contact with a personal
officer – were provided for him. He was in prison for the first time, on remand
and facing a very serious charge, and had distanced himself from his family.
It is only the account of his cell mate which has provided some insight into
what was happening during his time in custody. This investigation has
uncovered serious failings in the lack of management of the man who
managed to ‘slip completely through the net’.
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RECOMMENDATIONS
1. I recommend that the Governor and the Primary Care Trust ensure that all
healthcare staff are familiar with the relevant section of the Suicide Prevention
and Self-Harm Management Policy and Strategy Document.
The recommendation was accepted. All Portsmouth PCT staff are currently
receiving ACCT awareness training to case management level. The suicide
prevention and self harm policy is readily available to the HCC staff in the
ACCT policy box folder in the office for those on duty for reference and
guidance. During ACCT awareness training the SPC refers to the relevant
section during training for the familiarisation of PCT’s involvement in the care
of those at risk of self harm and suicide.
2. I recommend that the Governor ensures that the Foreign National Prisoner
Policy is implemented by all staff.
The recommendation was accepted. Complete – The Foreign National Policy
has been published and a local notice to staff generated.
3. The Governor should ensure that the personal officer scheme is working in
accordance with policy and that senior officers monitor it robustly.
The recommendation was accepted. The revised personal officer policy
document has been submitted to the Head of Custody and will be published
by the end of November 2009.
4. The Governor and Head of Healthcare, in collaboration with the Primary Care
Trust, should review the emergency medical response system.
The recommendation was accepted. This recommendation has been raised
in previous DIC action plans and completed in August 2009 with a new
system devised and a local notice to staff published.
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