Individual at Exeter

Investigation into the circumstances surrounding the
death of a man in August 2007
whilst a prisoner at HMP Exeter
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2008
This is the report of an investigation into the death of a man who died at the Royal
Devon and Exeter Hospital on, 17 August 2007 whilst a prisoner at HMP Exeter. He
was aged 42. I apologise for the delay in publishing this report.
I wish to offer my sincere sympathy and condolences to the man’s family for their
loss.
This investigation was conducted by one of the Ombudsman’s Senior Investigators.
I would like to extend my thanks to the Governor and his staff at Exeter for their help
and co-operation during this investigation. I also thank the prisoners who agreed to
take part in the investigation process.
A clinical review of the care and treatment received by the man whilst at Exeter was
conducted by a panel convened by the Devon Primary Care Trust. I am grateful to
the clinical reviewer and her team for their report.
This report highlights a theme common to many of the investigations carried out by
the Ombudsman’s office, that of medical confidentiality. As will be seen there is now
plenty of advice and guidance available to allow the sharing of confidential
information if it is likely to reduce risk of harm. The challenge appears to be to
spread the word at the grass roots level so that it can be done both properly and in
the best interests of the prisoners.
I have made three recommendations, which should be read in conjunction with those
made by the Clinical Review Panel.
Jane Webb
Deputy Prisons and Probation Ombudsman July 2008
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CONTENTS PAGE
Summary 4
The Investigation Process 6
HMP Exeter 8
Key Findings 10
Issues 29
Recommendations 36
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SUMMARY
The man was charged with a sexual offence and remanded into custody at HMP
Exeter on 20 April 2007. He had been at Exeter on previous occasions and was
known to many of the staff.
The man had a history of self-harming by cutting which he disclosed during the
reception process upon arrival at the prison. He also told staff that he drank a bottle
of spirits every day. As a result he was put on a Librium detoxification programme.
The doctor noted that he was mentally stable, not suicidal and had no thoughts of
self-harm.
The man applied for Rule 45 status, meaning that he wanted to be treated as a
vulnerable prisoner because of the nature of his charge.
Three days after arriving at Exeter the man cut his right forearm and wrist. He told
the doctor that he was angry about his charge and being back in prison. The doctor
opened an ACCT document and moved the man into healthcare. (An ACCT
document is part of a system that that supports and cares for prisoners who are
considered to be a risk of suicide or self-harm.)
There were no further acts of self-harm and the ACCT document was closed on 7
May. However, on 9 June, the man cut his right forearm, wrist and torso. He told
the officer who found him that he wanted to kill himself and that the television was
telling him to harm himself. Another ACCT document was opened which would
remain open until his death.
On 22 June, the man cut his neck and left arm. He told staff that he had been
frustrated by some legal documents he had received. He was later seen by the
prison doctor who found no evidence of any psychotic illness or suicidal intent.
Four days later another prison doctor referred the man for further mental health
assessment. That night the man smashed up his cell, claiming that he had read his
legal documents again. The following morning he told staff that his television was
talking to him which was why he smashed it. That evening the man began to
damage his cell again after arming himself with a chair leg. He was removed to the
Care and Separation Unit.
On 28 June, prison staff intercepted a letter the man had written in which he referred
to killing himself. Later that same day an adjudication was held in relation to the cell
damage. It was adjourned for the man to seek legal advice, but not before he had
started to use foul language towards the governor’s ‘Pudsey bear’ mug which was on
the desk. He said that he thought the mug was talking to him.
The man was seen by a psychiatrist on 4 July, who found no evidence of thought
disorder, delusions, hallucinations, cognitive disturbances or suicidal thoughts. That
afternoon the previous week’s adjudication was resumed and the man was punished
by three days cellular confinement, seven days loss of earnings and canteen and 14
days loss of television.
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The man self-harmed again on 8 July and 19 July and returned to Healthcare. He
returned to normal location and the next few days passed without incident.
Staff discovered the man on 30 July when he used a towel as a ligature and
suspended himself from the cell window. He was discovered by staff and cut down.
He had no injuries and apparently suffered no lasting effects. He was returned to
Healthcare.
On 10 August, the man moved back to D wing having applied again for Rule 45
status. His television was removed and he put in a complaint form asking for its
return. On 15 August, a senior officer returned the complaint form to the man with
his explanation as to why he could not have a TV at that time. One of the reasons
given was the number of TV’s that the man had damaged at Exeter during his
various periods of custody there.
The following day the man was not let out of his cell for evening association because
he had defaced the complaint form with foul language and put it under his cell door.
A prison officer checked his cell again and was sworn at and told to go away. A few
minutes later the same officer saw the man hanging behind his cell door.
Staff entered the cell and called for medical assistance. Cardio pulmonary
resuscitation (CPR) was performed until the paramedics arrived and took over. After
about 20 minutes the defibrillator showed a faint output from the man’s heart and he
was transferred to the Royal Devon and Exeter Hospital. The man was pronounced
dead at 11.17am the following day.
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THE INVESTIGATION PROCESS
1. The investigation was opened at HMP Exeter on 24 August 2007. The
Governor and his staff produced the man’s core record and a large number of
other documents for examination. Notices were displayed around the prison
to inform both staff and prisoners of the investigation.
2. A meeting was arranged with the investigating officer from Devon and
Cornwall Police. My investigator was able to discuss the progress of their
investigation and obtain copies of the statements they had taken.
3. My investigator formally interviewed a number of members of staff and
prisoners regarding the man’s death. The transcripts of those interviews are
attached at the end of this report.
4. One of the man’s brothers contacted my office shortly after his death. One of
my family liaison officers followed this up. She offered the opportunity to meet
with her and the investigator to discuss the purpose of the investigation and to
raise any concerns or questions that they would like explored and addressed.
The man’s parents, who reside outside of the country, further responded and
became the main point of contact for the man’s family. They have since
appointed a solicitor to act on their behalf.
5. My investigator contacted Her Majesty’s Coroner to inform her of the nature
and scope of my investigation and to request a copy of the Post Mortem
report. Upon completion, this report will be sent to the Coroner to assist with
her enquiries into the man’s death.
6. The Devon Primary Care Trust was asked to prepare a clinical review of the
care that the man received whilst at Exeter. A panel, chaired by the
Commissioning and Development Manager for the PCT, examined the man’s
medical record and other documents and produced a report of their findings.
One particular issue in their report, that the man changed his method of self-
harm from cutting to the use of a ligature, was also noted by my investigator.
I have chosen not to duplicate the panel’s recommendation on this matter but
I wholeheartedly support it. The panel made nine recommendations and
highlighted several areas of good practice.
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HMP EXETER
7. The prison is located within the city of Exeter and was built around 1850. It
currently has four accommodation units and a healthcare facility. Exeter
holds adult male remanded and convicted prisoners committed to custody
from Cornwall, Devon and southwest Somerset. Additionally it holds young
men between the ages of 18 and 21.
8. Ms Anne Owers, Her Majesty’s Chief Inspector of Prisons, writes in the
foreword to her December 2004 inspection report of Exeter,
“In an overcrowded, pressurised prison system, it is commendable that
managers at Exeter had succeeded in embedding the positive
developments we recorded at the last inspection, and had also achieved
considerable improvements in healthcare and resettlement. The main
focus of their attention now should be to improve both the amount and the
quality of activity available to prisoners”.
9. Later in her report when commenting on self-harm within the prison she
writes,
“The safer custody committee monitored self-harm and suicide matters
and acted to adjust policies and practice when required. Scrutiny of
F2052SHs revealed that initial care plans were meaningful and drew on a
good range of available resources, including psychiatrists, mental health
workers, chaplains, the Samaritans and Listeners and CARAT
(counselling, assessment, referral, advice and throughcare) workers.
Reviews were held punctually, were multidisciplinary and were again
meaningful. The quality of daily observation entries was mixed, with some
informative comments demonstrating good interaction and others merely
stating that the prisoner had been seen and appeared to be all right. Night
entries were not of a high standard, with some recording of movement but
none of interaction; many simply said ‘checked’. The timing of night
observations was generally at set intervals rather than random.”
10. Each prison has an Independent Monitoring Board (IMB). IMB members are
independent and unpaid. They monitor the day-to-day life in their local prison
or removal centre and ensure that proper standards of care and decency are
maintained. The IMB produces an annual report on their prison. In the
executive summary of the latest report for Exeter, 2006-2007, the chairperson
wrote:
“There are some very dedicated, professional staff working in Exeter
Prison.
Relationships between staff and prisoners are very good. Prisoners
generally feel safe in custody. However, we would like to see a more
purposeful and constructive use of prisoners’ time through the extension of
education, skills and leisure opportunities. The challenges of operating
within predominantly Victorian buildings designed for another age are
immense. The pressure of very high prisoner numbers adds to the
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difficulties and requires continuous attention to the maintenance of clean
and safe living and working environments. As monitors, we expect to see
creative management solutions to these problems in the coming year. The
IMB has full access to all prisoners and all areas of the prison.”
11. Since the Ombudsman was given responsibility for investigating deaths in
prisons in April 2004, there have been three deaths at Exeter prior to that of
this man. Two were apparently self-inflicted deaths and one man died from
natural causes. In two of those previous cases I made similar
recommendations for a coded radio system for use in medical emergencies.
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KEY FINDINGS
12. The man was arrested on 19 April 2007, on suspicion of burglary of a
neighbour’s flat. He was charged with a sexual offence at a Police Station on
20 April. The Prisoner Escort Risk form (PER) had medical condition,
violence, sex offence and suicide/self-harm ticked as risk factors. In the
further information section the police officer had written, “violent, self-harm,
sexual, heart complaint, depression”. (The PER form is used to communicate
perceived risk about a prisoner as he or she moves between police stations,
courts and prisons.)
13. The man appeared at a Magistrates Court later that day and was remanded to
HMP Exeter. Upon arrival at reception the man was taken through the normal
reception procedures. He told the reception officer that he had no next of kin
and that there was no one to contact in an emergency. He said that he was
unemployed. Answering questions for the Cell Sharing Risk Assessment form
(CSRA), the man told the officer that he had abused alcohol and was currently
dependent on alcohol.
14. The man was then seen by a health care worker who completed the First
Reception Health Screen. The man confirmed that he was not prescribed any
medication and had no injuries. He claimed to drink a bottle of vodka, rum or
wine a day but stated that he did not abuse drugs. The man was asked about
his mental health. He said that he had received psychiatric treatment outside
prison, citing the causal factor as his time in the prison in 2005. He said that
he had never received any medication for mental health problems and
admitted to self-harming by cutting his arms when he was in Exeter again in
November 2006. The man denied feeling like self-harming at the present
time. The healthcare worker noted that he seemed stable and aware of time
and place. He was referred to see the doctor for his alcohol misuse.
15. A prison doctor saw the man and noted that his general health was
satisfactory but that there was evidence of heavy drinking, again citing the
man’s assertion that he drank a bottle of vodka daily. The prison doctor noted
that the man was mentally stable, not suicidal and having no ideas of self-
harm. The doctor prescribed Librium for alcohol detoxification.
16. The man was taken to B wing, the First Night Centre/detoxification wing. This
is a section of the prison where most new reception prisoners spend the first
few days as their needs are assessed and they are inducted into prison life.
17. The man applied for Rule 45 status, meaning that he wanted to be treated as
a vulnerable prisoner. Exeter houses Rule 45 prisoners on D wing and part of
B wing as overspill. The man gave his reasons for wanting Rule 45 as being
the nature of his offence and the fact that he had been on Rule 45 in the past.
“Prison Rules 1999 as amended states: ‘Removal from association 45. -
(1) Where it appears desirable, for the maintenance of good order or
discipline or in his own interests, that a prisoner should not associate with
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other prisoners, either generally or for particular purposes, the governor
may arrange for the prisoner's removal from association accordingly.”
18. On 23 April, the man was seen by a probation officer working in the Offender
Management Unit. Her role was to conduct a basic needs analysis, assessing
concerns about debt, housing, drugs and alcohol. The man told the probation
officer that he had been staying with a friend but was unable to return as his
offence had taken place at a neighbour’s flat. She noted that he appeared not
to have had a settled address for a number of years following the breakdown
of relationships. He said that he had five children but was not in contact with
any of them, adding that his parents were living abroad. The man said that he
had neither been working nor claiming any benefits recently and now had
some debt. My investigator asked the probation officer about the level of debt
she believed the man to have, but she was unable to recall any details.
19. The probation officer recorded that the man was detoxifying from alcohol and
at times was quite tearful. During interview she said that was not unusual as
people newly into prison are often low and the man told her that he was
having problems coping with his thoughts without alcohol. He said that he felt
that he saw and heard messages and connections in what he saw and heard
around him. The probation officer spoke to him about what he should do if he
felt very low and the man said that he understood. The probation officer
referred the man to the housing advice officer, Action 4 Employment,
CARATS regarding his alcohol use and the prison healthcare unit. (CARATS
stands for 'Counselling, Advice, Referral, Assessment and Throughcare'.
CARAT workers act as keyworkers and coordinate the care of those prisoners
on their caseloads; workers can also provide basic information about drugs
and their effects and ways to reduce harm; they may offer some structured
one-to-one support and group work to prisoners who want to give up or cut
down on their misusing. They can also refer a prisoner to a drug treatment
rehabilitation programme.)
20. Later that day, at 1.00pm, the man was seen by the second prison doctor.
The man had made lacerations to his right forearm and wrist. He told the
doctor that he was angry at the charge and having to return to prison. He
added that he had been taking a vast quantity of alcohol for the last few
weeks due to not being able to settle in the community. The man told the
second prison doctor that he felt he got very little support from his family,
whom he thought judged him.
21. The man said to the second prison doctor, “I don’t want to be here”. During
his interview with my investigator the doctor said,
“That might literally mean I don’t want to be in prison but it also might
mean I don’t want to be in this life and I take statements like that seriously.
That might indicate thoughts of suicide. People might find it hard to say I
am going to kill myself and they put it in a covert way but the seriousness
of that remark shouldn’t be underestimated. If people say that when they
are harming themselves, are withdrawn, having the body language of
being down and out, you shouldn’t underestimate it.”
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22. The second prison doctor opened an ACCT plan. (ACCT stands for
Assessment, Care in Custody and Teamwork. The plan encourages staff to
work together to provide individual care to prisoners in distress, to help defuse
a potentially suicidal crisis or to help individuals with long-term needs, such as
those with a pattern of repetitive self-injury, to better manage and reduce their
distress.)
23. The man was located in a single cell in healthcare. The immediate action
plan stipulated that the man was not to have a television or his shoelaces but
could access a telephone or talk to a Listener. (A Listener is a prisoner who
volunteers to be trained by the Samaritans to provide a similar confidential
service to other prisoners.)
24. It was noted in the ACCT assessment interview that the man,
“Presents as quite incongruent – feels that he would like to have cut a vein
today but also would like to attend video link 24.4.07. Does not express
any plans to further self-harm or take his life.”
25. The video link referred to above is a video link from the prison to a
Magistrates Court in Devon.
26. The man passed a quiet night, but at 8.45am on 24 April he was caught trying
to conceal his medication. It was noted that he was cross at being caught. At
9.10am he attended the video link and his case was remanded until 22 May.
27. At 12.20pm the man spoke with the third prison doctor saying that he could
not cope either in or out of prison and that he wished to die. The doctor noted
that he should remain in healthcare at that time, that he accepted all his meals
and interacted well with others during association. Later that day the man told
staff that he regretted saying that he wanted to kill himself and had been
angry when he said it.
28. The next few days passed without incident and on 30 April the man attended
an ACCT review. The prison doctor decided to discharge him from the
healthcare unit but to keep him on the ACCT plan. A nurse noted on the
review that the man’s presentation was that of a quite truculent man who,
unless he was gaining what he wanted, declined to interact much. The man
was moved to D wing and into a double cell. It was later recorded on his
ACCT plan that the man had a good evening and was mixing well with his
cellmate.
29. The man was monitored on the ACCT plan over the next week. He appeared
to be in good spirits, watching television and interacted well with staff and
other prisoners. On 7 May, another ACCT review was held. A senior officer
recorded on the case review sheet that the man was,
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“a completely different man from the last time we met. He is currently
presenting as bright, cheerful, positive and has different outlook on his
future. Good eye contact and is sleeping and eating well. Is completely
finished his detox and is feeling much better. All in agreement to close
ACCT.”
30. Seven days later on 14 May, at an ACCT post closure interview, the man told
the staff that he was coping well and was happy with the way things were
going for him. Everyone present agreed that the ACCT plan should remain
closed.
31. The man appeared to settle well into prison life for a while. An entry in his
main record for 20 May states,
“Good humoured and sociable on the wing. No episodes of paranoia, as
encountered during previous custody.”
32. Seven days later, on 27 May, an officer wrote in the man’s main record that
there was no change from the previous entry (above) and that the man
seemed to just want to serve his sentence as quietly as possible.
33. On 9 June, shortly after 6.00pm, the man rang his cell bell to be allowed out to
use the toilet as there are no in cell facilities on D wing. The second prison
officer thought that the man was taking a long time so he went to check. He
found the man in the toilet area and saw that he had cut himself. The man
had apparently taken a disposable razor and used the blade to harm himself.
He offered the blade to the officer when he was found. The second prison
officer summoned medical aid and a nurse attended. She wrote, both in the
medical record and the main record, that the man had deep lacerations to his
inner right forearm as well as cuts to his wrist and torso. The man was tearful
and said, “I want to kill myself”. He also said that the television was telling
him to harm himself.
34. The man’s wounds were dressed and he was taken to healthcare. The out of
hours doctor service was contacted as the man’s cuts required stitching. The
second prison officer opened another ACCT plan for the man as the result of
the self-harm. He wrote that the man said that he wanted to kill himself
because he could not cope with being “inside or outside”.
35. The out of hours doctor treated the man’s cuts and he was admitted to
healthcare. At 2.30am the following morning the man asked for and was
given two paracetamol tablets for pain in his arms. It is recorded that the man
was abusive and verbally aggressive at 8.30am and remained so for the rest
of the day. The nurse wrote in the ACCT plan that she was unable to carry
out the assessment interview due to the man’s fractious nature. She had
attempted to check his wounds but was met with abuse. The man’s cuts were
re-dressed by another nurse but he again became aggressive and abusive
afterwards, punching the hatch as staff tried to talk to him. It was decided that
two Control & Restraint officers should be present whenever the man was
unlocked.
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36. The nurse conducted the ACCT assessment interview on 11 June. The man
told her that he had not been coping on the wing due to his current situation
(in prison for the current charge). He said that he made the cuts on his arm
because he did not want to carry on, but he went on to say that he was
relieved that he did not die. The nurse, who is a registered mental health
nurse, recorded her thoughts about the man’s current mental state, saying
that he was very stressed, anxious and emotional. He was not hearing voices
or having hallucinations nor reporting panic attacks. The man stated that he
was not currently thinking about self-harm or suicide and had no plans to
harm himself.
37. On 12 June at 11.15am, the man was seen by the prison doctor in healthcare.
The man wanted to be discharged from healthcare and the doctor agreed. He
prescribed a short course of chlorpromazine to help with the man’s anxiety.
38. The man returned to D wing and the shared cell he had previously occupied.
Later that day an officer noted that the man was happy to be back on D wing
with his cell mate and that his medication was having a profound effect as he
was very cheerful.
39. On 18 June, the man refused to go to education and according to staff, was in
quite a belligerent mood. He also put in an application to come off Rule 45.
By the afternoon it was recorded that the man had calmed down and he
apologised for his behaviour. An ACCT review was held at 3.45pm. The man
said that he was feeling a lot more settled although he was still having mood
swings. It was decided that the ACCT plan should remain open.
40. Two days later whilst at a class, the man became very agitated and began to
cry when he was asked to write a short life history. The senior officer
contacted the mental health in-reach team who agreed to see him. The next
morning the man was very agitated, tearful one minute and angry the next.
The senior officer referred him to healthcare because of his surly behaviour
and attitude. The man was seen by a nurse at 3.20pm. She wrote that he
was very angry and agitated but was unable to identify a specific reason for
his feelings. He blamed the police, his family and the prison staff for his
situation. He was tearful and frustrated but denied any immediate thoughts of
self-harm. The man agreed to daily outreach with healthcare staff and agreed
that he would tell them if he did not want to talk. Both the nurse and the
senior officer were concerned for the safety of the man’s cell mate due to the
man’s anger. The senior officer reviewed the CSRA and made it ”high”. The
nurse discussed the man’s case with the second prison doctor who agreed for
him to move into a single cell.
41. At 9.00pm that night the officer spoke with the man. The man said that he
was a lot happier on his own.
42. At 11.45am on 22 June, staff noticed marks on the man’s neck. When he was
asked about them he said that he had cut his neck and left arm due to
frustration after receiving some legal documents the day before and then ‘not
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being right’. Healthcare staff were called to clean and dress his wounds. The
healthcare worker recorded in the medical record that the man claimed to
have caused the wounds the previous afternoon. She referred him to the
doctor.
43. The man was seen by the prison doctor at 6.35pm. The man told him that he
did not like the wing and that people were saying things about him and an
officer who was friendly to him. He was also worried about his case. The
prison doctor recorded that he found no evidence of any psychotic illness or
suicidal intent.
44. On 23 June, the D wing officer wrote in the main record that the man’s
behaviour was becoming increasingly erratic and bizarre. At 4.00pm, a third
senior officer made a similar entry in the ACCT plan, adding that he felt staff
should be cautious when working with the man.
45. Three days later, on 26 June, the man was seen by a fourth prison doctor.
She referred him to see the prison in-reach mental health team. The doctor
wrote the following on the referral form,
“Inmate presents as agitated and troubled. He is possibly confused; he
sometimes feels he is getting messages from the TV. His speech is
thought disordered at times. He becomes distracted and loses eye
contact. He has self-harmed – cuts to neck and forearms. Currently
taking chlorpromazine 25mg. He needs further mental health
assessment.”
46. At 10.30pm staff heard noise coming from the man’s cell. Upon investigation
they found that he had ”smashed up” his cell. The man said that he had done
it because he had read his reports again.
47. On 27 June at 8.00am, the D wing officer noted both in the ACCT plan and
the main record that the man was extremely volatile when his cell was
opened. The man was claiming that the previous night his television was
talking about him, which was his reason for smashing it. He also accused
other prisoners of stealing his tobacco and talking about him. At 10.55am, the
man was found damaging his cell again. On this occasion, he had armed
himself with a chair leg. At 12.15pm, the man was moved to the Care and
Separation Unit because of his behaviour. He was put in one of the cells with
an in-cell camera which allowed staff to view him more easily. The camera
did not however record the images.
48. When a prisoner is located in the Care and Separation Unit (also known as
the segregation unit or the ‘seg’) an initial safety screen form must be
completed, part of which is a segregation safety algorithm. The segregation
nurse completed the algorithm on this occasion at 12.30pm. Her decision
was that there was no healthcare reason for the man not to be segregated.
My investigator asked the segregation nurse during her interview if she had
any concerns about the man being segregated. She replied,
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“No, if I had I wouldn’t have made him fit for cellular confinement. I spoke
to the man on that occasion, I was present when he was taken from the
cell on D Wing and taken to the Separation and Care Unit, I was present
all the way with him. He was very angry, very verbally abusive, didn’t co-
operate very well at all with the Officers during the move, so it was quite
difficult for them as well. And when he was located in the cell in the
Separation and Care Unit I went in and spoke to him. I asked him if he
had injuries, if he wanted to report anything to me and he just said, ‘no’.
He had calmed down and he said no and on that occasion I didn’t feel that
he was mentally unfit to be able to be located in the Separation and Care
Unit.”
49. At 12.45pm a governor checked and signed the form as required by the
protocols. It was also decided that the man could be allowed tobacco and a
lighter in his cell and standard furniture.
50. The prison doctor saw the man in the Care and Separation Unit at 3.35pm.
His assessment was “behaviour rather strange – showing no evidence of
psychotic illness. I feel his behaviour is not compatible with medical illness.”
51. At 5.00pm that day an ACCT case review was held. The man was not
present, because of his previous volatile behaviour. It was noted that the man
was calm at that time and that another review would take place after the
adjudication to be held the next day. The remainder of the day passed without
incident.
52. When a prisoner breaks the prison rules an adjudication takes place with a
prison governor acting as the adjudicator. The governor hears the evidence
against the prisoner, gives the prisoner the opportunity to put his case and
then makes his/her decision. If the case is proved the usual punishments are
loss of privileges and or earnings.
53. The following morning, 28 June, a letter written by the man was intercepted by
correspondence staff. In the letter, which does not have an addressee’s
name, the man wrote about killing himself. A Security Information Report
(SIR) was submitted and a number of relevant people were informed,
including the fourth prison doctor, healthcare, and the Safer Custody Unit.
54. At 1.00pm, another governor held the adjudication. The governor explained
some of what took place during his interview for this investigation,
“I opened the adjudication and the man requested contact with his legal
representative for advice. The norm is to allow them seven days to do
that, that is either by mail or preferably they can get a phone call to their
solicitor. So it appears that the man requested contact with his solicitor
which I granted, I allowed him seven days but during the adjudication
process he became aggressive and the proceedings were halted and he
was returned to his cell, in the Separation and Care unit. As a result of
that plus what the original offence, alleged offence of him being there I
didn’t deem it appropriate for him to return to ordinary location and
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therefore I signed him on good order or discipline for an initial period of 72
hours”.
55. Good order or discipline, also known as GOOD, is Prison Service Rule 45
which states,
“Where it appears desirable, for the maintenance of good order or
discipline or in his own interests, that a prisoner should not associate with
other prisoners, either generally or for particular purposes, the governor
may arrange for the prisoner’s removal from association accordingly.”
56. Another officer gave another view of the man’s behaviour during the
adjudication in his interview,
“Okay, I think he had two charges for disorder and damages which is the
charge we lay for breaking prison property, I think it was threatening and
abusive behaviour towards the staff who tried to intervene, the previous
afternoon he had calmed down considerably, I don’t think I had a problem
out of him all the evening. So the following day eight o’clock we start, the
adjudication starts about ten o’clock, I don’t think there was a problem with
him in the morning, when he came into the governor about ten o’clock, he
wasn’t in familiar surroundings, he wasn’t just speaking to me or my
colleague in his cell, he was now in a different room within the unit, talking
to the governor. He wasn’t familiar with the governor because halfway
through the adjudication he started talking to the mug on the table which
was a Children in Need Pudsey Bear mug, he thought that the bear was
talking to him. He was trying, he was about to start to have an argument
with the mug, saying that the mug was looking at him, and he has got no
right to look at him. I think he was using foul and abusive language
towards the mug, at which point the governor I think said that he was unfit
to carry on in adjudication, so me and my colleague just escorted the man
back to the cell and it was as if nothing had happened, he just went back
into the cell and was calm again.”
57. Another ACCT review was held at 2.30pm. The man said that he did not have
any self-harm thoughts at that time. The review officers were aware that he
had been allowed seven days to take legal advice. It was decided to keep the
ACCT open.
58. On 29 June, the man was seen by a nurse from the mental health In-reach
team. It was recorded that he was hostile during the interview but not
distressed. There was evidence of possible paranoid thoughts as the man felt
that he could talk to the programmes on the television. The entry ended with
the nurse saying that the man needed to see the psychiatrist on Wednesday
morning (4 July).
59. At lunchtime on 30 June, the man refused his lunch and then began head
butting the cell door. He blocked the toilet with a towel, which was removed
by staff. Later that afternoon he was reported as having a very aggressive
16
and angry hour, refusing his medication and being extremely abusive to staff.
He also refused his evening meal.
60. The man appeared to have a peaceful night, but the following day he would
not communicate with staff and he refused breakfast and lunch. His tea meal
was placed in his cell as he had not eaten all day. The man did say that he
would take his medication as well when the nurse came.
61. On 2 July, an officer wrote in the ACCT plan that after having his cell camera
lens unblocked twice, the man had a very aggressive and angry morning.
The man had ripped his clothing off, tried to flush it down the toilet, put his
head into the toilet bowl, banged his head, punched the cell door and
screamed abuse. That lasted about 30 minutes then the governor spoke with
the man and he calmed down. The rest of the day was calmer with staff
reporting that the man had been compliant, had taken his medication and left
his cell to collect his tea.
62. The following day staff reported that the man was well behaved, calm and that
he took his meals.
63. On 4 July, at 9.45am the man had a psychiatric review with a doctor. The
doctor recorded in the man’s medical record that he found him coherent,
relevant and lucid. He found no evidence of thought disorder, delusion,
hallucinations, cognitive disturbances or suicidal thoughts. The man said that
he felt okay now and did not have any mental health or health problems.
64. That afternoon the man attended his adjudication (a day early because of the
weekend). It is not recorded whether he had spoken to his legal
representative since the last hearing. The governor decided to impose a
punishment of three days cellular confinement, seven days loss of earnings
and canteen and 14 days loss of television.
65. On 5 July, a segregation officer recorded in the ACCT plan that the man had
said that he felt a lot better, was happier and engaging more with staff. The
officer acknowledged that the man did look better and seemed happier. Later
that day at 7.30pm the same officer noted that the man had had his best day
for quite a while, including joking with staff.
66. At 2.55pm on 6 July, another ACCT case review was held. It was noted that
the man had come a long way during the last few days. The man said that it
was his birthday the next day and that was no longer an issue for him. He
said that he had no more thoughts of self-harm and did not want to go
backwards. Although both staff and the man agreed that the ACCT should be
closed, it remained open and the observations continued.
67. Just before 6.00pm that evening, the man moved back to B wing. He had
completed his cellular confinement days. The man’s birthday passed without
incident, but the following day, 8 July, it was recorded that he was feeling low
again.
17
68. At 2.00pm, an ACCT case review was held. The man presented as very
confused and rambled a lot about the cause of his stress. It was noted that
he was unable or unwilling to elaborate on what he was saying. He kept
talking about the voices in his head, but became increasingly angry when
asked what could be done to help him. Eventually, the man left the review in
an agitated state and returned to his cell. The senior officer who had
conducted the review, increased the perceived risk from ‘low’ to ‘raised’. He
spoke with a nurse about the man seeing a doctor.
69. Before that could happen the man self-harmed again. At 3.45pm, a B wing
officer opened the man’s cell and noticed blood on the floor. The man was in
the toilet area and out of sight. The officer asked what had happened and the
man said that he had fallen over. The officer then approached the man in the
toilet area and saw that his arms were covered in blood from cuts to his arms.
The man was holding a razor blade which he put in the sink when he was
asked.
70. The man was taken to healthcare where his wounds were cleaned and
dressed. The wounds did not require sutures. He was admitted to
healthcare. As a healthcare in-patient on an ACCT, the man would have
been observed five times an hour as well as casual observations by staff
going about their routines. As one member of staff explained in her interview
with my investigator, the only higher level of observation is a constant watch,
which as it suggests means continuous observations by a member of staff.
The man settled into the regime in healthcare.
71. On 10 July, the man explained to the doctor that his thoughts were racing and
that he found relief from his anxiety and anger by self-harming. This was
recorded in his medical record.
72. During the afternoon of 11 July, after a healthcare team discussion it was
decided to allow the man to have a television.
73. On 13 July at 12.07pm, a healthcare nurse recorded in the ACCT plan that
the man had attended association that morning but had not been in a good
frame of mind. At 5.00pm, the man asked to speak with a Listener as he did
not wish to talk to staff.
74. At an ACCT case review held on 14 July, the man talked freely about how he
felt and explained that he self-harmed to cope with things in his past. He said
that he became homeless, got in with the wrong crowd, and drank heavily
then his mental health went down. The man told the staff that he felt safer in
healthcare and only had occasional thoughts of self-harm. He said that he
found talking with a Listener very beneficial and he was finding it difficult in
prison this time.
75. The man appeared to be settled for a couple of days, although when the
healthcare nurse asked him if he was okay at lunch on 16 July, he replied that
he was not. He would not elaborate but said that he just wanted to eat his
lunch. A little later he threw some water and punched his television. Later
18
that day it was recorded that the man was much calmer and that he had said,
”I was just pissed off this morning”. He also said that he was trying to give up
smoking.
76. At 11.30am on 17 July, the man attended another ACCT review prior to being
discharged from healthcare. A governor, the segregation nurses and both the
third prison doctor and the prison doctor were at the review. It was reported
that although the man felt more settled whilst in healthcare he acknowledged
that it was not appropriate for him to remain there. The man said that he
wanted to come off Rule 45 as he did not wish to return either to D wing or
B4. The man agreed that he would seek help or support either from the
landing or healthcare staff. In turn, the man was told that appropriate
healthcare support would be put into place to help him on the landing. As part
of the new care plan it was decided that any superficial self-harm should be
dealt with on the wing.
77. My investigator asked the segregation nurse why the man could not simply
remain in healthcare as it appeared to suit him better than the wings. She
replied,
“Because as far as we were concerned from the entries that we had made,
there was no need, the man was not self harming, he was not being a
management problem, he wasn’t having any medical intervention that he
couldn’t receive on ordinary location which could be provided through
Outreach, so the nurse could go and see him. The mental health team
could go and see him on the ordinary location. He didn’t need to be in a
hospital environment, his needs could be met on the landing, so we don’t
keep people in healthcare for their sentence. Once they are settled, they
are telling us that they are ready to move back on to the wings. Then we
will put in place in their ACCT documents if they are on one, and we also
do if they are not on an ACCT document, we do a discharge plan which
goes in the front of their IMR which the nurses on Out-patients can read,
tells them a little bit about why they are in healthcare and how they should
be looked after initially on their discharge.”
78. An officer who works in healthcare noted in the man’s main record that the
man became truculent when he was told that he was being discharged from
healthcare. Whilst out of earshot of the staff he threatened one of the
orderlies. However he was moved to B wing without incident. At 5.20pm, he
declined both his medication and his food and did not reply to the officer who
asked how he was. The officer wrote, “Perhaps he is not happy being on B
wing, would probably prefer to have remained on HCU.”
79. At 10.00am on 19 July, the man made multiple cuts to his right forearm, some
through the full skin thickness and others to the right side of his neck. The
second prison doctor thought the cuts were potentially serious and admitted
him to healthcare. The man’s injuries were treated with ‘steri-strips’ and dry
dressings. It is clear from the second prison doctor’s entry that he did not
have either the ACCT or medical record to hand when he saw the man. The
second prison doctor explained during his interview that the man was
19
bleeding when he was brought to him. The second prison doctor said that he
would not have expected staff to worry about the paperwork under those
circumstances.
80. The man settled back into life in healthcare. On 20 July, a third prison doctor
and the nursing team agreed that the man could return to normal location and
to a shared cell, subject to a satisfactory risk assessment. On 24 July,
following an ACCT review, the man relocated to C wing. During the review he
expressed a wish to share a cell and he was advised to speak with the wing
staff. There is no record of him asking to share a cell but in any case the Cell
Sharing Risk Assessment was marked as high due to his unpredictable
behaviour.
81. The next few days passed without incident. On 30 July, the man spoke to one
of the landing staff. The officer tried to put the man at ease but recorded later
that the man thought the staff might be trying to catch him out. The officer
told the man that the staff were always available to him and that seemed to
reassure him. Another officer spoke with the man a couple of hours later, at
7.30pm. The officer felt that he seemed a little uptight, saying, “You guys
know what is up, you are always asking me.” The man then assured the
officer he was alright. However the officer was not happy and decided to
check the man again 15 minutes later.
82. At 7.45pm, the officer returned to the man’s cell with a colleague and found
the man hanging from the cell window. He had used a towel as a ligature.
The officers cut the ligature. No resuscitation was required and there was
only a mild irritation to the man’s neck. He was seen by the prison doctor,
who admitted him to healthcare once again. The man had written a suicide
note which the officer described as rambling. The officer told my investigator
that he took the note to healthcare with the man but since then the note
appears to have been lost. The note is not mentioned by any of the staff who
cared for the man after this act of self-harm.
83. The following morning at 9.00am, the man told staff that he was okay, but
later was seen punching his pillows and was generally angry. It was noted
that he was ”rude and truculent” when seen by the doctor. At 4.00pm, a
senior officer from the wing noted that the ACCT review was to be deferred
until 1 August due to the man’s uncooperative presentation.
84. At 3.00pm on 1 August, the man attended an ACCT review. He told the staff
that he had tried to hang himself because he felt like he was going mad. He
said that he did not know if it was because of the way he was being treated or
because he had lost control. The man said that he self-harmed due to
uncertainty about his case and his previous charges. He repeated that he
harmed himself out of anger and frustration.
85. After the review the man spent the afternoon associating with the other
prisoners without problems. The healthcare nurse recorded that later, whilst
waiting at the treatment hatch, the man became very angry about something.
20
When she asked him what the problem was he stormed off without giving her
an answer.
86. On 2 August, the nurse asked the man how he was feeling, to which he
replied, “Do you really care miss?” She told him that she did. Later, at
12.44pm, the healthcare officer spoke at length with the man. He told the
officer that he was finding it very difficult to cope with prison this time. He said
that he had received threats whilst on the wing as the result of previously
being on Rule 45, and that other prisoners questioned him too much about his
offence. The officer noted that the man did not mention any intention to self-
harm but did say that he had difficulty coping with being angry and was
impulsive.
87. The man remained generally calm and settled until 8 August, when he went to
Exeter Crown Court. Initially he was talking and responding to staff but later
became quiet and withdrawn. The man said that he thought that the staff
were laughing at him and he also got upset with his barrister during a legal
visit. He arrived back at Exeter at 2.15pm when it was recorded that he was
”not happy – very quiet”. The man remained settled and calm for the next 24
hours.
88. At 3.30pm on 9 August, an ACCT case review was held prior to the man
being discharged from healthcare. Earlier he had made an application to
return to Rule 45. He wrote his reason for the request as ”vulnerable
prisoner”. His request was agreed by a governor. He was to remain in
healthcare until space became available on D wing. At the review it was
noted that the man had been in healthcare since 30 July and had not self-
harmed or threatened to during that time. It was agreed by the review team
that once he was discharged the man would be re-admitted on a crisis
intervention basis for an overnight stay unless the reason for admission was
severe. Superficial acts of self-harm were to be treated on the wing.
89. The man moved to D wing at 4.30pm on 10 August. The senior officer
recorded the prison doctor’s instructions that the man’s cell was to be kept
available should he need to go to healthcare following an act of self-harm.
The man’s television was removed from his cell when he arrived back on D
wing. My investigator was told that the man had broken several televisions
during his time in custody and there was also concern that on occasion he
would tell staff that the set was talking to him. The man put in a complaint
form that day stating,
“Regarding TV removal when I arrived back on D wing, Fri 10th.
Previously on healthcare 9 days and C wing prior, so alright with TV in
presence.”
In the section “What would you like to see done about your complaint?” he
wrote, “TV returned and trusted with appliance”.
90. The next two days passed without incident. On 12 August, the man was seen
by the senior officer for the purposes of carrying out a Cell Sharing Risk
21
review. It was recorded again on that form that the man had broken six
television sets. The senior officer decided that the man remained a high risk
to a cell mate.
91. The senior officer spoke with the man the following afternoon and wrote in the
ACCT record that he “had great difficulty elucidating any real information from
the man due to his incoherent rambling”. Later however, the man mixed well
with the other prisoners during association.
92. During the day of 14 August, the man was recorded as being unhappy. He
asked about coming off Rule 45 and declined lunch, but took his tea meal and
medication later. The last ACCT entry that evening reads, “Has been in a
strange mood during the evening, talking to himself a lot. Left him lying on his
bed.”
93. On 15 August, an officer made two entries in the man’s ACCT record, and
one in his main record.
“12.30 – At times has a normal conversation and at other times goes on
rants about cameras watching his every move – unpredictable.
17.30 – Improved as day went on, though quiet, seemed in a better mood.
Has been behaving in strange manner over the last couple of days. No
control problem at present, but needs watching.”
94. During the day the senior officer returned the complaint form that the man had
submitted on 10 August. He wrote in the response section,
“ I have informed you of the reason why you currently do not enjoy the
privilege of an in cell TV. To date you have destroyed six televisions.
Your actions have a knock on effect of depriving the next person who is
located in your cell of a TV. As the D wing manager and a crown
employee I have a duty and responsibility to ensure public property is
looked after. Your damage of six TV’s demonstrates to me you are unable
to treat prison property with the respect it deserves – I would also remind
you that the damage you inflicted on each of the six appliances rendered
them beyond repair. I am not ruling out you being supplied with one in the
future but your current unpredictability precludes you from the facility of a
TV at present.”
95. At 8.00pm, the D wing officer wrote in the ACCT record, “A bizarre evening
behaviour, talking to empty cell D1 – 9. Otherwise quiet, prefers to remain in
cell.”
96. The following morning the man was let out of his cell so that he could get the
equipment to clean it. He got into a confrontation with another prisoner. The
man accused the other man of staring at him. He became very aggressive
and began shouting at the other prisoner. An officer defused the situation and
the man returned to his cell. The man told the officer that there were too
22
many cameras on the wing and that people were staring at him. When asked
what could be done to help, the man said that he wanted to come off Rule 45
and go back into the main prison.
97. The man attended another ACCT review at 10.05am on 16 August. The
senior officer was the case manager and two other officers were present. The
senior officer wrote on the review form that the man had much recent
evidence of self-harm on the inner aspect of each forearm. The man said that
he did not need to be on the ACCT. The officers felt that the majority of the
review was taken up with the man’s incoherent ramblings and claims of
hearing voices. In his interview with my investigator, the senior officer said
that the man claimed that Fearne Cotton was talking to him from the
television.
98. The senior officer concluded the review record by writing, “The H.C.U claim
he is not mentally ill but, but those present are of the opposite opinion. It was
felt that, all things considered, he should stay on this ACCT.”
99. At 12.20pm, the D wing officer noted in the ACCT record that the man’s
primary concern was to move back to the main prison. He added that the
man insisted he was okay.
100. In fact the man had put in an application to come off Rule 45 and move back
to the main prison, stating his reason as “hopefully feel comfortable on the
main now. Came back to D wing after being released from hospital wing. To
adjust etc.”
101. A principal officer approved the man’s application at 2.30pm, noting that the
man was aware of the inherent risks and that he had been on normal location
before. The man was to move to C wing the following day. The risk that the
principal officer was referring to was the possibility of a negative reaction from
other prisoners. (A lot of prisoners think of those on Rule 45 as being sex
offenders and do not want to associate with them.)
102. At 2.17pm and 2.28pm, the man tried to telephone his brother, first on his
home and then his mobile number, but neither call connected. During his time
at Exeter, the man attempted to make 13 calls but did not actually speak with
anyone. Exeter’s pin phone clerk checked the man’s record and confirmed
that at the time he had credit on his account and so there was no obvious
reason for the last two calls not to go through.
103. As part of the investigation process notices were placed around the prison to
notify prisoners of the investigation. Two prisoners on D wing asked to speak
with my investigator although only one prisoner wished to go on the record.
104. The prisoner said that he was the man’s friend, although they had only known
each other since he had been at Exeter. On the afternoon of 16 August, the
prisoner spoke with the man on D wing. He said that the man was really edgy
and anxious. The man had received the reply about his television and was
not happy about it. The man was at his cell door and said to the other
23
prisoner, “That’s it; I’m going to kill myself tonight.” The prisoner said,
“What?” The man said, “No, no, I’ve had enough, I ain’t staying here no
longer. That’s it, I’m going to do it tonight”. The prisoner said that the man
then shut his cell door and locked it, ending the conversation.
105. At 4.35pm the primary healthcare manager visited the man to check on how
he was settling in on the wing. In his interview with my investigator, the
manager described the man as,
“Appearance wise he was quite relaxed, pleased to see me. We basically
had a chat about how things were going and I could see from the cell that
things were tidy. He had no recent self-harm or any injury that I could see
to him at that time, he gave me no cause for concern with his appearance
or anything in his behaviour or conversation really.”
106. My investigator said to the healthcare manager, “Thinking back on your earlier
interview, can you think of anything that gave you any sort of indication at the
time?” the manager replied,
“No, the most surprising thing for me is that one minute I was having a
chat with him and a few hours later it was such a fatal situation. There
was nothing that I could have picked up in anything that he said or was
doing or how he appeared in front of me. There were no visual clues to
anything being untoward for him.”
107. When the primary healthcare manager left the man’s cell, the prisoner took the
manager into his cell to speak with him. The prisoner told my investigator,
“So I grabbed the healthcare team, talked at teatime as I was getting my
meal, I pulled him in my cell, he was there for a good five minutes. I said,
I’m really concerned about him over there, he’s going downhill, somebody
needs to do something with him and I told him straight there and then, I
think he’s going to kill himself, well he’s threatened to kill himself.”
108. The prisoner said that the healthcare manager assured him that he would take
on board what he had told him.
109. The conversation with the prisoner was not recorded, neither was it mentioned
to my investigator during his interview with the primary healthcare manager.
The manager later verbally confirmed that he had spoken with the prisoner
about the man that day but said that the prisoner had not told him about the
man’s intention to kill himself.
110. At 5.30pm the senior officer recorded on the ACCT document that the man
had taken his tea meal and appeared to be chatty and his usual self. (At
Exeter prisoners eat their tea meal while locked in their cells.)
111. The D wing officer said in his statement to the police that he last saw the man
at 6.00pm when he did his final roll call before going off duty. The officer said
24
that the man was lying on his bed reading a book and that he gave a ‘thumbs-
up’ when the officer looked in.
112. At 6.27pm (time from CCTV), the officers on D wing began to open the cell
doors for the association period. A prison officer was about to open the man’s
cell door when a prisoner asked him if he was sure he wanted to do that. At
that time the officer noticed a sheet of paper that had been slipped under the
cell door. The prison officer looked at the paper and realised that it was a
complaint form. It was, in fact, the form that the man had submitted asking for
a television. The officer saw that ‘fuck off pig’ had been written on the bottom
of the form and the senior officer’s reply had lines across it.
113. A prison officer described the sequence of events in his interview:
The prison officer: “…Through the spyhole, I hadn’t unlocked the door.
The man was acting peculiar in the cell, he was acting … my concerns at
that point were compounded by the other prisoner stating that, you know,
are you sure you want to unlock the prisoner, and to explore it further, I
made a decision at that point not to unlock the man. I went to speak to the
other officer, raised my concerns, we agreed not to unlock him at that point,
to just monitor for a while.
Investigator: You said that he was acting peculiarly in the cell, can you …?
The prison officer: He was just fidgety, maybe agitated, non-committal,
wouldn’t speak to me, look at me, things to that effect.
Investigator: So then you had gone back and spoken to another officer and
decided not to open him up just at that point …
The prison officer: Just at that point, yes. Didn’t mean he wasn’t going to
be opened up, not just at that point. However when I went back to see him
at 1900 hours (CCTV shows 18.38) once again on his bed reading a book
and he told me to ‘fuck off’ at that point, rather aggressively, so I wasn’t
going to unlock him at that point. We also had another prisoner come into
the office and made a statement to the effect that there had been some
problem on the landing and again some of the prisoners were concerned in,
I wouldn’t say frightened, of his behaviour. So we both took the decision
not to unlock him. We continued to monitor him. Which I did.”
114. At 7.13pm (CCTV time) the prison officer returned to check on the man. He
found that his view into the cell through the door hatch glass was mainly
blocked. He saw the man’s back high up on the door and thought he was
suspended. The officer returned to the landing office and told the other officer
that he thought the man was hanging.
115. The other officer rang the control room and asked for Hotel one (the
emergency healthcare response officer) to come to the landing as there was a
medical emergency. The officers locked the prisoners back into their cells
and then entered the man’s cell at 7.15pm (CCTV time).
25
116. The officers had to force their way into the cell as the man’s body weight was
against the door. They found the man hanging off the ground, suspended by
the neck from an overhead pipe. He had tied socks together to make the
ligature.
117. The prison officer used his personal issue anti-ligature knife, referred to as a
‘fish knife’ due to its shape, to cut through the socks while the other officer
supported the man’s body weight. Once the ligature was cut, the man’s
weight proved too much for the officer but nevertheless he managed to
manoeuvre him onto the bed. Both officers then put the man onto the cell
floor. The prison officer, who was First Aid trained, checked for a pulse but
found none.
118. When the officers laid the man on the cell floor they placed him, they believed,
in the recovery position. Very shortly after, at 7.18pm (CCTV time), a nurse
arrived at the cell. The nurse was ‘Hotel one’ that day, but did not know what
kind of emergency he was attending. He had queried the emergency call as
he was busy in Reception and had been told that it was urgent but no more.
119. The nurse found the man lying flat on the floor, not in the recovery position.
He turned the man onto his back and checked for signs of life. He did not find
any and he noted that the man’s face and hands were blue in colour. The
nurse started cardio pulmonary resuscitation (CPR) by means of chest
compressions. He applied a resuscitation mask over the man’s mouth and
nose and used that to blow air into the man’s lungs.
120. Whilst carrying out CPR, the nurse told the two officers to call for an
ambulance urgently and to get the fourth prison doctor, who was in reception.
At 7.21pm, the officer in the control room was informed by the other officer
that the man had attempted suicide and an ambulance was required.
121. The CCTV shows the fourth prison doctor arriving at the cell at 7.24pm. She
assisted the nurse with CPR until the paramedics arrived six minutes later, at
7.30pm.
122. Some water had been spilt on the floor of the cell so the paramedics decided
to move the man out onto the landing to get him clear of the water. The
paramedics attached a defibrillator to the man’s chest but the machine did not
register any cardiac output. The man was intubated (a tube was placed into
the man’s throat to ensure a clear airway) and adrenaline was administered.
CPR continued. At about 7.50 pm, the defibrillator showed spontaneous
activity from the man’s heart. The paramedics decided to move him to a local
hospital and at 7.55pm the ambulance left Exeter and took the man to the
Royal Devon and Exeter Hospital.
123. No suicide note was found either at the time or when the police arrived later.
124. Just after 8.00pm, the senior officer arranged for the D1 landing prisoners to
be let out of their cells. He spoke with the prisoners, advising them what had
26
happened. He also told them that Listeners were available if any of them
were traumatised or distressed.
125. The staff involved were spoken to by the staff care team that evening but no
‘Hot’ debrief took place and no other debriefing session involving the staff has
been held since. (The purpose of a ‘Hot’ debrief is to acknowledge what
happened, acknowledge the role of the staff involved, normalise the situation
and ensure that immediate needs of the staff have been met.)
126. One of the prison chaplains was notified and he went to the hospital to be with
the man. After some difficulty, due to the lack of next of kin information, one
of the man’s brothers was contacted by the police and he and his wife arrived
at the hospital at 12.15am. The Governor of Exeter was also present. He
and the prison chaplain spoke to the man’s relatives. The prison chaplain
later prayed with the family before leaving them to be with the man.
127. At 11.17am the next day, a doctor certified that the man had died in the
Intensive Care Unit.
27
ISSUES
Television
128. I believe it was clear from the time the man first arrived at Exeter that he might
be a challenging prisoner to care for. He was already known by some of the
staff from previous periods at Exeter. The man’s reputation for smashing
televisions emanated from those times in custody, and no less than seven
security reports relating to smashed televisions have been located in earlier
records.
129. The fact that the man had smashed a number of televisions was recounted to
my investigator by a number of officers during the investigation. The
impression given was that it had happened during his most recent time in
custody, yet when the documents were checked the only mention of him
damaging prison property was on 26 June. There was one record of him
punching his television (no damage recorded) on 16 July. It is clear from the
records that the man could sometimes have an unusual relationship with his
television, saying that he could talk to the programmes or that they were
talking to him. Those factors and the self-harm danger from broken parts,
taken together, would easily justify removing the television. However, a lot of
the time when it was recorded in the ACCT document that the man was calm,
the observation was also made that he was watching television.
130. I am not convinced that a prisoner’s current care should be unduly influenced
by damage to a television or a number of televisions during previous times in
custody.
Change of self-harm method
131. The man was known at Exeter as a man who would self-harm by cutting, yet
on 30 July he was found hanging from the window in his cell. The man did
not self-harm by cutting again. Although it is not clear if the healthcare staff or
other staff were aware of the suicide note I believe the change of method
should have been noted and should have triggered a mental health review.
This view was shared by the Clinical Review Panel, who have made the
following recommendation.
When there is a change in a prisoner’s pattern of self-harming, such as
application of a ligature rather than cutting, this should trigger a review
and a reassessment of the individual by a psychiatrist.
Sharing confidential information
132. This investigation has once again highlighted a divergence between the
medical staff and the discipline staff at prisons. The man was assessed by a
psychiatrist, three doctors and other healthcare staff. In their opinion the man
was not mentally ill. Very often non-medical staff find it hard to know how
best to handle and care for prisoners like the man. After what was the last
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ACCT review on 16 August, the senior officer wrote, “The HCU claim he is not
mentally ill but those present (at the review) are of the opposite opinion.”
133. Very often during my investigations discipline staff complain of the lack of
feedback they receive after they bring any health concerns, particularly about
mental health, to doctors or nurses. My investigator was told that there is no
formal documented pathway for those concerns to be passed, with a phone
call or chance meeting on the wing being the usual method. It is not unusual
for discipline staff to be waiting eagerly for a psychiatrist to assess a prisoner
about whom they have genuine mental health concerns. The assessment is
duly carried out but nothing is fed back to the wing staff who have 24 hour
responsibility for that prisoner.
134. Medical confidentiality is usually the reason cited by healthcare staff for the
lack of information given to discipline staff. There appears to be a belief by
the staff (not only at Exeter) that they are not allowed to share medical
information. In his introduction to ‘Safe and Secure’ – Guidance for
healthcare staff on information sharing’ Head of Offender Management
Partnerships – Department of Health and Director of Health and Offender
Partnerships – National Offender Management Services wrote:
“Although staff from all organisations involved with justice and secure care
systems have always been willing to cooperate with and assist each other
where possible, concerns over unlawful disclosure of sensitive and
personal data have constrained sharing of information with, at times, tragic
results. Whilst concerns to stay within the laws and guidance governing
disclosure of information are justified and laudable, they have at times
been misplaced.”
135. A review of patient-identifiable information was commissioned by the Chief
Medical Officer for England as a result of increasing concern about the ways
in which patient information is used in the NHS, and the need to ensure that
confidentiality is not undermined when information is passed between NHS
organisations or between the NHS and other organisations. The report of the
review – the Caldicott Report – was published in December 1997. Following
the report there has been a requirement for each NHS organisation to
nominate a senior person, preferably a health professional, to act as a
guardian to be responsible for safeguarding the confidentiality of patient
information. These guardians have become known as “Caldicott Guardians”.
136. Caldicott Guardians act as a focus for information sharing issues which relate
to patient information that has been provided in confidence. The responsibility
for protecting and using patient information continues to lie with the whole
organisation. The Caldicott principles which govern the use of confidential
information are as follows:
(cid:127) Justify the purpose(s) for using personally-identifiable information.
(cid:127) Only use when absolutely necessary.
(cid:127) Use the minimum that is required.
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(cid:127) Access should be on a strict need to know basis.
(cid:127) Everyone should be aware of their responsibilities.
(cid:127) Understand and comply with the law.
137. Another important recommendation of the Caldicott Committee was that
protocols should be developed to protect the exchange of patient-identifiable
information between NHS and non-NHS bodies.
138. The Devon PCT code of confidentiality (June 2007) lays out clear guidelines
for when confidential medical information can be disclosed and to whom. At
present there is no specific section dealing with prison discipline staff but I
believe that they could be classified as ‘carers without parental responsibility’.
The guidelines for disclosure to those persons are as follows,
“Only information essential to a patient’s care should be disclosed and
patients should be made aware that this is the case. However, the explicit
consent of a competent patient is needed before disclosing information to
a carer. The best interests of a patient who is not competent to consent
may warrant disclosure.”
139. The code sets out what is required for “explicit consent” as follows,
“When seeking explicit consent from patients, the approach must be to
provide:
(cid:127) Honest, clear, objective information about information uses and their
choices – this information may be multi-layered, allowing patients to
seek as much detail as they require,
(cid:127) An opportunity for patients to talk to someone they can trust and of
whom they can ask questions, reasonable time (and privacy) to reach
decisions, support and explanations about any form that they may be
required to sign,
(cid:127) A choice as to whether to be contacted in the future about further uses,
and how such contacts should be made, and
(cid:127) Evidence that consent has been given, either by noting this within a
patient’s health record or by including a consent form signed by the
patient.
The information provided must cover:
(cid:127) A basic explanation of what information is recorded and why, and what
further uses may be made of it,
(cid:127) A description of the benefits that may result from the proposed use or
disclosure of the information,
(cid:127) How the information and its future uses will be protected and assured,
including how long the information is likely to be retained, and under
what circumstances it will be destroyed,
(cid:127) Any outcomes, implications, or risks, if consent is withheld (this must
be honest, clear, and objective – it must not be or appear to be
coercive in any way), and
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(cid:127) An explanation that any consent can be withdrawn in the future
(including any difficulties in withdrawing information that has already
been shared).
(cid:127) The information provided must allow for disabilities, illiteracy, diverse
cultural conditions and language differences.
Any consent obtained must be recorded with details of:
(cid:127) Who gave consent
(cid:127) When it was given
(cid:127) What purposes
(cid:127) Any limitations to the consent.”
140. Whilst I am not suggesting wholesale disclosure of confidential medical details,
I do believe that when the need arises prisoners should be asked to sign a
consent form allowing information to be shared with senior wing staff. Having
a clear policy for disclosure would help prison healthcare staff to recognise
that in certain circumstances such disclosure is both lawful and beneficial.
Prison Service Instruction (PSI) 25 of 2002 ‘The Protection and Use of
Confidential Health Information in Prisons and Inter-agency Sharing’ (still in
force) laid much of the groundwork for such a policy, but it is clear that in the
six years since its introduction the mindset of the majority of prison healthcare
professionals has not been changed.
141. I am pleased to see that the latest version of Prison Service Order (PSO) 2700
published in October 2007 highlights this issue in Section 6,
“There are strong links between self-harm and mental ill health,
drugs/alcohol problems, and experience of abuse. Other problems such
as bereavement and, especially for women, the loss of children to the care
system are common causes of distress to prisoners. All are issues that
staff caring for prisoners need to be aware of and watch for; both in terms
of the related risks to the prisoner, and around what specialist support is
available to help the prisoner. Also, the often repeated findings from PPO
investigations into deaths in custody and HMIP reports cannot be
emphasised enough, concerning the need for healthcare staff to share risk
and basic care information with discipline staff who manage a prisoner”
(emphasis in the original).
142. In May 2008, the Director of Offender Health, Department of Health, NOMS,
wrote a letter to PCT Prison Health Leads, Prison Governing Governors and
others. He wrote about ten best practice issues from 120 PPO reports.
Number 8 in the list was;
“Promoting an integrated approach to the care of people in prisons
The reports have demonstrated some differences in the aims and cultures
of NHS and Prison Service at local level that may compromise working
relationships on the ground. For example, evidence exists in the care of
people with mental illness that a lack of willingness to share information
may reduce opportunities to identify significant changes in mood and
warning signs of decline in mental health”.
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The Healthcare Manager together with the Devon PCT should draw up
and publicise widely a procedure for healthcare staff at Exeter to
implement a clear policy for the obtaining of consent and the
subsequent disclosure of prisoners’ confidential medical information to
realise both the letter and spirit of Section 6 of PSO 2700. The
effectiveness of the new arrangements should be formally reviewed
within six months of their introduction.
Conversation between a prisoner and the Primary Healthcare Manager
143. When the primary healthcare manager was interviewed by my investigator he
did not mention that the other prisoner had approached him after he left the
man’s cell on the afternoon of 16 August. The prisoner said that he had
spoken to the healthcare manager and expressed his concerns about the man
after he had said that he intended to end his life that day. When my
investigator spoke with the manager again he agreed that the prisoner had
spoken to him about the man but that the conversation centred on the
prisoner’s concern that the man would start getting angry in the food queue at
tea time.
144. There was obviously a conflict between the two accounts. If the prisoner’s
account was correct the manager, a registered mental nurse, should have
realised the import of what the prisoner had told him and taken action. For
that reason and in line with my terms of reference the Governor was told of
the situation and then the investigating police officer was informed and given
copies of the interviews.
145. Both parties were interviewed by the police. I understand the prisoner did not
repeat that he had actually told the manager that the man had said he
intended to kill himself that day. The police investigation has been reported to
HM Coroner and, together with my report, will form part of the evidence
available at the inquest.
Emergency radio system
146. I investigated the death of another man at Exeter in January 2005. One of the
recommendations in that report was that the Healthcare Manager should
consider introducing a coded radio system for alerts. Many prisons have
introduced such a scheme where, for instance, a medical emergency
involving blood is a code red, one involving a prisoner not breathing or having
trouble breathing a code blue, etc. Such a coded system has the advantage
of alerting all staff to the type of situation they may find upon arrival at the
given location.
147. In the man’s case, the nurse was busy in Reception when he received the call
over his radio. Even when he queried the nature of the call, the control room
officer was unable to give the nurse any details as he himself had not been
given any.
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148. Finding a person hanging is a stressful experience and often staff find it
difficult to recall times and exactly what they said or did. A coded system
would ensure that the essential information was conveyed quickly. It would
also allow the medical staff to arrive at the location with the relevant staff and
equipment. The nurse would have brought a defibrillator to the man’s cell if
he had known the kind of emergency he was attending, although in this case I
do not believe the lack of equipment had a negative impact. Ideally an
ambulance would have been called as soon as the man was discovered
hanging and would have been if the control room had the specific information
from the outset.
The Governor together with the Healthcare Manager should introduce a
radio colour code system for use by staff in medical emergency
situations.
Lack of hot debrief
149. Neither the staff who found the man in his cell on 16 August nor those
subsequently involved were asked to attend a ‘hot’ debrief that evening or any
other debriefing session later. This is in contravention of the guidelines laid
down in Prison Service Order (PSO) 2710 and PSO 8150. I am aware that a
‘hot’ debrief was not held after another man died at Exeter by his own hand, in
September 2007.
“PSO 2710 paragraph 5.3 states: There must always be a hot debrief
immediately after the incident and provision for this should be made in
local contingency plans. A senior member of staff must act as debriefer
and a duty care team member must also attend. (Italics in original) The
purpose is not to analyse or re-live the incident. Nor is it an opportunity to
apportion blame or pre-judge investigation findings. The hot debrief should
focus on reassurance, information sharing, normalisation and how staff
can support each other. Particular reassurance is needed when the
prisoner died after unsuccessful resuscitation attempts, when staff
involved are more likely to feel a sense of failure. Staff wanting but unable
to attend the debriefing should be followed up, as a group or individually.
Refer to PSO 8150 for guidance about Critical Incident Debriefs and
longer-term support and specialist treatment.”
Section 1 and 6 of PSO 8150 states:
“1. Immediately following a potentially traumatic incident- identify, inform
and debrief. In the immediate aftermath of the incident, before the staff
involved go home, it is important that managers identify all staff who were
involved and provide them with a short debrief, known as a “Hot” debrief.
Within 5-10 days of a potentially traumatic Incident- Critical Incident
Debrief.
6.1The purpose of a Critical Incident Debrief is to:
(cid:127) Give staff involved in an incident the opportunity to discuss the personal
impact of the incident with others involved.
(cid:127) Encourage and enhance mutual support.
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(cid:127) Provide information on the effects of Post Trauma Stress.
(cid:127) Normalise Post Trauma Stress reactions.
(cid:127) Encourage coping strategies and support networks.
6.2 A Critical Incident Debrief will automatically be offered when the
Incident is categorised as potentially traumatic and when there are more
than 2 members of staff affected. When only 1-2 members of staff are
affected, they can be referred (if necessary and with their consent) to
Employee Support for an individual support.”
The Governor should ensure that the relevant sections of PSO 2710 and
PSO 8150 are complied with in relation to debriefing sessions following
a death in custody.
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RECOMENDATIONS
1. The Healthcare Manager together with the Devon PCT should draw up and
publicise widely a procedure for healthcare staff at Exeter to implement a clear
policy for the obtaining of consent and the subsequent disclosure of prisoners’
confidential medical information to realise both the letter and spirit of Section 6 of
PSO 2700. The effectiveness of the new arrangements should be formally
reviewed within six months of their introduction.
2. The Governor together with the Healthcare Manager should introduce a radio
colour code system for use by staff in medical emergency situations.
3. The Governor should ensure that the relevant sections of PSO 2710 and PSO
8150 are complied with in relation to debriefing sessions following a death in
custody.
Recommendations from the Clinical Review Panel
1. Where patients report positive responses to questions on the secondary health
questionnaire, then action and consideration by an appropriate health
practitioner should be recorded in the patient’s notes.
2. The use of a summary sheet to record major events should be maintained and
include incidents of self harm, and prison health care unit in-patient admissions.
3. When calling healthcare to an emergency on the wings they should be made
aware if it is a suspected suicide.
4. When there is a change in a prisoner’s pattern of self harming eg application of a
ligature rather than cutting, this should trigger a review and reassessment of the
individual by a psychiatrist.
5. Care plans for reviewing patients following admission and/or requiring continuing
wing support, should clearly state the frequency and objective of future
consultations, with a clear criteria for discharge and readmission.
6. Assessment proformas should be comprehensively completed by staff.
7. Discipline staff who discover a casualty not breathing and with an absent pulse
should be appropriately trained to initiate CPR, whilst specialist assistance is
summoned.
8. When a serious incident occurs which could result in a death in custody the
Primary Care Trust Commissioner should be informed the next working day via
the healthcare manager or their deputy.
9. A mechanism should be in place to request a prisoner’s previous GP records via
the PCT for prisoners serving a sentence of longer than six months.
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Good practice identified by the Clinical Review Panel
(cid:127) A comprehensive discharge plan was prepared by healthcare staff, summarising
recent care and future care needs.
(cid:127) The time between a primary care referral and assessment by a psychiatrist was
appropriate and timely.
(cid:127) Resuscitation is particularly traumatic in a prison setting; the extensive efforts of
the attending nurse and paramedics in supporting this prisoner should be noted
and commended.
(cid:127) The level of support which was provided from the multidisciplinary team should
be commended.
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