Individual at Belmarsh

Investigation into the circumstances surrounding the
death of a man
at HMP Belmarsh in March 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is the report of an investigation into the death of a man at HMP Belmarsh in
March 2007. The man was found hanging in a ward in the healthcare centre. He
was 43 years of age. My colleagues and I offer sincere condolences to the man’s
family and friends for their sad loss.
This investigation has been undertaken by my colleague. I would like to thank the
Governor of HMP Belmarsh and her staff for their participation in the investigation.
Particular thanks go to the liaison officer.
A multi-disciplinary panel was convened to undertake the review of the man’s clinical
care on behalf of Greenwich Teaching Primary Care Trust (PCT). This consisted of
clinical professionals. I greatly appreciate their assistance.
After his arrival at Belmarsh on 24 May 2006, no concerns were raised about the
man until six months later when, on 24 November, he cut his wrist. He was then
located in a gated cell in the healthcare centre on constant observation. The next
day, the man banged his head twice in the cell and this resulted in him going to
outside hospital. Little more than a month after he harmed himself, the man was
referred for assessment for a place at a psychiatric hospital. Throughout his time in
the healthcare centre, between 24 November and 3 March 2007, the man developed
an immovable paranoid belief that he was going to be killed by the Security Service
(MI5) and that his family were involved. At times he also refused to eat or drink. He
was evidently in a very disturbed mental state, but was adamant that he did not have
any suicidal or self-harm intentions. He did not self harm between 25 November and
his death.
On 28 December 2006, the man moved from constant observation in a gated cell to
a single cell where he was on intermittent watch. On 12 January 2007, the man was
assessed by a specialist registrar from a medium secure unit who concluded that he
was acutely psychotic and needed to be assessed urgently for transfer to a high
security hospital (Broadmoor) under section 48 of the Mental Health Act. On 16
January, the man was transferred to a six bed ward at Belmarsh. He appeared to
settle in well with the other prisoners on the ward. Throughout his time in the
healthcare centre, the man was regularly reviewed by the psychiatric team. The
man was waiting for an assessment for admission to Broadmoor when he died. The
clinical review concludes that the man was referred and assessed for admission to a
high security psychiatric hospital in a timely way, but his transfer was complicated by
his category A status. (Category A is the highest security category for holding
prisoners in custody.)
The clinical review has raised a number of concerns regarding the man’s care. My
report includes four recommendations based largely on that review. .
This version of my report, published on my website, has been amended to remove
the name of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2009
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CONTENTS
Summary
The Investigation Process
HMP Belmarsh
Key Findings
Events on 3 March 2007
Issues
Family concerns
Clinical care
ACCT management
Recommendations
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SUMMARY
The man was remanded in custody at HMP Wormwood Scrubs on 17 May 2006
charged with possession of firearms. During the initial health screen, the man said
he had stomach troubles for which he was taking prescribed medication. He said he
did not have any other physical ailments. The man denied that he had any problems
with drugs or alcohol. Finally, the man was adamant that he had never had any
psychiatric problems and had never tried to harm himself. The man was transferred
to HMP Belmarsh on 24 May.
No concerns were raised about the man until 24 November 2006 when he cut his left
wrist in three places. The man was placed on an ACCT (Assessment, Care in
Custody and Teamwork) form, and located in a gated cell on constant observation in
the healthcare centre. (ACCT is the system used by HM Prison Service to monitor
and support a person at risk of suicide or self harm. Constant observation is where a
prisoner is observed by a designated member of staff who remains constantly in his
or her presence (in accordance with each establishment’s local strategy). The man
was convinced he was going to be killed but would not say by whom.
On 25 November, the man cut his head twice by banging it against hard surfaces in
the cell. He was taken to hospital after the second incident. On 3 December, it was
noted in the man’s medical record that he had lost a significant amount of weight.
His weight on 18 May was recorded as 79kg and this had dropped to 66kg by 3
December. The man believed he had been accused of being an informant and that
the Secret Services (MI5) were looking for him. The man was referred for an
assessment to transfer to a secure psychiatric hospital.
The man remained on constant watch until 28 December and he had regular reviews
and input from the psychiatric team. He declined medication and became
increasingly paranoid. On the next day, the man was moved to a single cell in the
healthcare centre and he was placed on intermittent (30 minute) observation. The
plan was for staff to watch his food and drink intake as he was refusing to eat or
drink.
On 12 January 2007, the man was seen by a specialist registrar from a medium
secure unit who concluded that the man was suffering from delusional persecutory
beliefs. He felt that, if there was no significant improvement in the man’s mental
state, he should be assessed for urgent transfer and treatment in a high security unit
under the provisions in section 48 of the Mental Health Act. On 15 January, the man
started taking the antipsychotic medication, Olanzapine. Two days later, the man
was moved to a six bed ward in the healthcare centre.
On 19 January, the man was eating better and had been taking his medication since
15 January. The man was not eating again by 31 January and said he wanted to
starve himself. He complained that he had been suffering from stomach pains for
two days. The man was due to see a doctor about the stomach pains but this did not
happen.
On 15 February, a consultant psychiatrist at Belmarsh, wrote to a Crown Court to
recommend they delay sentencing the man until he was assessed for transfer to a
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high security unit. The psychiatrist pointed out that the process could take some
time as the man was a category A prisoner. The regular reviews by the psychiatric
team identified that the man had ‘persecutory paranoid delusional beliefs’. The man
was not consistent in taking his medication and at times refused to eat or drink.
The man was waiting to be assessed for transfer to a high security unit when he was
found hanging on 3 March 2007.
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THE INVESTIGATION PROCESS
1. My investigator studied all relevant prison records relating to the man. These
included his main prison record, medical record and statements made by
prison staff.
2. Greenwich Teaching Primary Care Trust (PCT) was asked to carry out a
review of The man’s clinical care. I am grateful for this review being
undertaken in a timely manner.
3. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation, and to request a copy of the Post Mortem
report. This records the cause of death as hanging. My report will be sent to
the Coroner to assist him in his enquiries into the man’s death.
4. One of my family liaison officers and my investigator met the man’s partner in
the company of her solicitor. The man’s partner raised various concerns
which are addressed later in this report in paragraphs 84 to 88 under ‘family
concerns’. I hope this report will help the man’s family better understand what
happened in the time leading up to his death.
5. My investigator discussed aspects of the man’s treatment with both staff at
Belmarsh and the clinical reviewers. Notices were issued to staff and
prisoners telling them of the investigation and offering them the opportunity of
contributing. During the course of the investigation, 22 members of staff were
interviewed including the head of the healthcare centre. My investigator
spoke with two prisoners and with the police in relation to their investigation.
All statements taken by them were also obtained.
6. My investigator has been unable to interview three members of staff who are
on long term sick leave.
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HMP BELMARSH
7. HMP Belmarsh opened in 1991. It is a local prison that can hold category A
prisoners (the highest security category). Most of its 915 prisoners are
accommodated on four residential houseblocks. Houseblock 1 contains
mainly life sentence prisoners, although no specific sentence planning or
courses for lifers take place at Belmarsh. Life sentence prisoners are held
until appropriate spaces for them can be found elsewhere in the lifer estate.
8. Together with HMP Brixton, Belmarsh has piloted the model for treating
prisoners with mental health problems in a ‘community’ setting. The
healthcare centre (HCC) is a three storey building that includes a 33 bed in-
patient unit. The in-patient beds are mainly used for prisoners requiring
psychiatric care. The HCC has four gated cells which can be used for
prisoners needing constant observation.
9. There is also a day care centre for prisoners with mental health conditions
(the Cass Unit). In April 2005, Greenwich Teaching PCT assumed
responsibility for commissioning healthcare services in the prison. The head
of healthcare leads a multi-disciplinary team of nurses, healthcare officers,
discipline officers and nursing assistants, and there is input from a Mental
Health In reach Team (MHIRT), visiting GPs and a consultant forensic
psychiatrist. There are two staff care psychiatrists and four community forensic
psychiatric nurses, a social worker, two occupational therapists, an
administrator, and an in-patient manager.
10. The most recent report by HM Chief Inspector of Prisons, Dame Anne Owers,
in October 2005 came after a full announced inspection and report in May
2003. Dame Owers’s October 2005 report says:
“Most of our 2003 recommendations about healthcare had not been
addressed, although prisoner perceptions about the quality of healthcare
and the service from doctors had improved. There was a very limited
regime for in-patients, who had poor access to regular exercise and limited
association opportunities. The Cass Unit for prisoners with mental health
conditions was closed regularly.”
11. The man’s death was the fourth apparently self-inflicted death to occur in
Belmarsh since I began investigating fatal incidents in prisons in April 2004.
There are common issues between this inquiry into the death of The man and
two of my previous investigations. I shall refer to these later in my report.
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KEY EVENTS
12. The man was remanded in custody at HMP Wormwood Scrubs on 17 May
2006 charged with possession of firearms. The man saw a member of
healthcare staff who completed the first reception health screen form for him.
The purpose of this form is to gather medical information from the prisoner
about his physical and mental health. The man said that he was being treated
for stomach problems for which he was taking prescribed medication,
Omeprazole. The man said he did not have any other physical ailments. He
also said that he did not have any problems with drugs or alcohol. Finally, the
man was adamant that he had never had any psychiatric problems and had
never tried to self harm. A general health assessment was also completed
(on 18 May) when no additional ongoing health issues were identified.
13. The man was transferred to HMP Belmarsh on 24 May due to his category A
status. There is no evidence of the reception health screen being repeated.
The induction checklist says that the initial screening form was completed but
it is not in the paperwork. A cell sharing risk assessment was completed for
the man and it was concluded that he would not be a risk to anyone else
sharing with him.
14. The man appeared to settle at Belmarsh and no concerns were raised until 21
June 2006 when he complained that his heart was racing and he had
palpitations. He was seen by a healthcare officer who referred him to a
doctor. The man was examined by a prison doctor the next day. The doctor
concluded that the man’s problems had possibly been related to excessive
caffeine intake and he taught him some relaxation techniques. No other
issues or concerns were raised until 24 November.
15. At around 11.00pm on 24 November, the man cut his left wrist in three places.
He was examined by the doctor who cleaned the cuts and closed them with
steri-strips. At around 11.55pm, a principal officer (PO) opened an ACCT
form. The man said that he was worried about his impending court
appearance in January 2007. He also told the PO that cutting his wrist had
been an impulsive act and he would not self harm again. The man was seen
by a registered mental health nurse (RMN), who completed an ACCT
assessment interview with him at around 00.25am on 25 November. The
RMN noted that the man’s mood seemed low and he had general anxiety
about his court case. The RMN also noted that the man’s act of self harm had
been impulsive. The man was admitted to the healthcare centre for constant
observation in a gated cell.
16. The man was seen by a healthcare worker, and a senior healthcare officer
(SHCO), for his first ACCT case review on 25 November. The man had
suddenly and without warning become paranoid that ‘people’ were going to kill
him. He was also anxious about his court case. He asked the healthcare
worker how long the human body could last without food or water. The man
was placed on a food monitoring regime and his weight was to be checked
weekly.
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17. At around 2.15pm, the man cut his head after apparently hitting it against the
bed. The wound was cleaned and dressed by a nurse, but the man refused to
have sutures or further treatment from the duty doctor. The man signed a
disclaimer confirming this. The man had a visit from his partner later that
afternoon.
18. Between 6.30pm and 8.00pm, he again smashed his head open, possibly
against a sharp edge in the cell. An entry in the ACCT form says that he
stood on the table in the cell and deliberately jumped down head first. The
table and chair were immediately removed from the cell. The man was
transferred to an A&E at a local hospital They took x-rays and the wound was
closed with sutures. There was no fracture to the head. The man returned
from hospital at around 00.25am on 26 November and remained on constant
observation in a gated cell in the healthcare centre. He was quiet but
paranoid and suspicious.
19. On 26 November, the man refused to leave his cell and expressed paranoid
thoughts. He said that he feared for his own safety and for the safety of his
family. He remained on constant watch. The prison doctor contacted a
psychiatrist at home to discuss the man’s treatment. The psychiatrist a
consultant psychiatrist at Belmarsh. He recommended that the man be
prescribed anti-anxiety drugs. The man was subsequently prescribed a low
dose of Lorazepam, although initially he refused this and any other
medication. Later on he saw his co-defendant on the authority of a governor.
The governor felt that this meeting might help the man who was paranoid and
did not trust any of the staff. The man expressed concerns that his partner
and children had been killed and he could not be reassured that this had not
happened. The governor spoke to the man’s partner as the man was so
concerned about her. After the telephone call, the governor told the man that
his family was fine and he seemed relieved that she had spoken to them. The
governor said that the man’s partner was concerned about the man and could
not understand why he was feeling the way he was.
20. The man was assessed by a psychiatrist, on 27 November. The psychiatrist
saw the man in his cell, and the man said he had felt depressed since being in
prison and away from his family but felt alright in the healthcare centre. When
the psychiatrist said he would see him the next day, the man said, ‘Tomorrow
never comes. I won’t be here tomorrow.’ He gave the psychiatrist permission
to speak to his solicitors. The psychiatrist spoke to the man’s solicitors and
they confirmed that, in a meeting with them on 20 November, he had been
tearful but had become calmer towards the end of the meeting. The man also
told the psychiatrist that his partner was due to visit him, but he appeared
convinced she was dead. The psychiatrist also noted that the man had not
been eating.
21. The psychiatrist spoke to the man’s partner on 27 November and made a note
of the conversation in the man’s medical record on 28 November. The man’s
partner had visited him on 21 November. She told the psychiatrist that before
the visit she had not detected any problems with her partner. The man’s
partner said that when she saw him on 21 November he was not making
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sense, his conversation was limited and he appeared like a stranger. She
said that her partner had been looking around and questioned her about what
was happening. He said to her, ‘Now the penny has dropped.’ The
psychiatrist asked the man’s partner some questions about him, such as their
background, any previous contact with psychiatric services and the man’s
previous employment. He told her that the diagnosis was unclear and they
were going to keep her partner in the healthcare centre to continue observing
and reviewing him.
22. Later on 27 November, the man’s partner visited him with one of their sons.
This was a special visit and took place in the healthcare centre. The man told
her that the prison was bugged and people were spying on him. The man’s
partner noticed that he had lost weight and he said to her, ‘I won’t be here for
too long’ and ‘Don’t believe them’. The man told her he was being accused of
being an informant and someone was going to kill him. The man’s partner felt
it was very out of character for him to behave like that. The man told his
partner that he could not remember what had happened when he cut himself,
but that he would never commit suicide.
23. The man refused to come out of his cell later on 27 November and said
‘Tomorrow is not over yet’. The man repeatedly said he would not be here
tomorrow and that he would be killed. He told the psychiatrist that he could
not be helped and that he would see him in the next world.
24. The man was seen by a doctor on 28 November. He refused to leave the cell
and would not let the doctor enter it. The man sat with his back to the wall
and repeatedly said that he would be killed that night. He said he had felt
scared for around a week and over the past year he had felt paranoid at
times. The man was unable to give the doctor any proof that he was in
danger and he refused any medication. He denied he was suicidal. The
doctor’s opinion was that the man had delusional views.
25. On 29 November, the psychiatrist saw the man again. The man told him that
he thought he was going to be killed by someone but would not say by whom
and added it was a hunch. He told the psychiatrist that he did not trust
anybody. The man maintained his view that his partner and children were
dead, despite having had a visit from his partner on 27 November. He told
the psychiatrist that his partner had not looked well. The psychiatrist noted
that the man smiled and laughed during the interview. He appeared
dishevelled and was not sure about taking any medication.
26. On 30 November, the man’s possible referral to an open regional secure unit
was discussed during a management ward round. (Management ward rounds
are weekly meetings attended by most of the mental health team, two doctors,
the psychiatrist, and the community psychiatric nurses (CPNs). Other
members of healthcare also attend as appropriate and if available. All
prisoners who are under psychiatric care are discussed during these
meetings.) One of the doctors recommended that the man should be referred
for transfer to a medium secure unit. The doctor explained to my investigator
10
that the aim was to gradually build up trust with the man so he would
eventually agree to take his medication.
27. On 1 December, the man was reviewed by the psychiatrist. The man told the
psychiatrist that he believed his (the man’s) partner was going to be killed. He
was suspicious of any examination of his mental state. The man was also
adamant that he was going to be killed but would not say who was going to kill
him. He said he would never kill himself. As part of the referral process the
psychiatrist needed to find out further information about the man, including
details of his conviction. He contacted the man’s solicitors and they told him
that his case was now being handled by another firm. The psychiatrist also
contacted with a medium secure forensic psychiatrist unit regarding the man’s
referral. The unit agreed to fax a referral form to the psychiatrist. The
psychiatrist recommended that the man remain on constant observation and
his food and drink intake monitored.
28. The man had a visit from his partner and daughter on 2 December. The
meeting went well and it was noted in his ACCT by an officer that the man
interacted well. The man and his partner were both in tears at the end of the
meeting.
29. On 3 December, an ACCT review was undertaken by a charge nurse and a
senior officer (SO). The man said his self harm had been a mistake and was
adamant that he was not going to hurt himself although he continued to
believe he was going to be killed. He told his partner not to visit him any
more. The man remained on constant watch. The charge nurse also
completed a secondary health screen for the man. She weighed him and
noted that his weight was 66kg, whereas it had been 79kg on 18 May 2006.
30. On 4 December, the man told the psychiatrist that he had changed his
solicitor as his previous solicitor had ‘stitched him up at the back.’ The
psychiatrist noted that the man was sleeping and eating normally and he felt
that the man’s persecutory beliefs were not as intense as they had been. The
man told the psychiatrist that the visit with his partner on 2 December had
been ‘fine.’
31. On 5 December, the man had a visit from his brother. He saw the psychiatrist
after the visit and told him it had gone well. However, the man said he was
scared to go to the visit with his partner in the afternoon. The man spoke to
his partner on the telephone and told the psychiatrist that she was fine. The
man spoke to the psychiatrist about his brothers being shot and killed in
Ireland.
32. On 7 December, a note made after the management ward round said that
there had been a gradual improvement in the man’s mental state and he was
less preoccupied than before. Later that day he told the psychiatrist that his
car had been bugged by the police and he believed the intelligence agencies
were going to kill his partner. The psychiatrist’s conclusion at that time was
that the man had persecutory beliefs but they were not of ‘delusional
intensity’. The psychiatrist discussed with the man whether he would like to
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move to a ward. The man said he was not ready to be with other prisoners
but felt he would cope in a single cell. The psychiatrist decided to keep the
man on constant observation and review him the following week.
33. The man had an ACCT review on 10 December, completed by an officer and
a nurse. The man told them he was alright. However, he became angry
towards the nurse when she asked him when he was going to court. The man
said he did not have any thoughts of self harm and was looking forward to
going to court in January. The man’s level of risk of self harm was still
considered to be high.
34. The psychiatrist saw the man again on 11 December. The man still believed
that he was going to be killed, but again would not elaborate. The man told
the psychiatrist that his weekend had been fine, he had been on the phone to
his family and had no concerns. The man complained he had been suffering
from cold legs and numbness in both knees for two days. The psychiatrist
noted that he was wearing shorts. The psychiatrist concluded that the man
appeared calm but was slightly anxious. The man told the psychiatrist that he
did not have any suicidal thoughts. He had a legal visit that afternoon and
remained on constant watch.
35. On 13 December, the man was seen again by the psychiatrist. The man was
feeling low as Christmas was coming and he would not be with his family. He
told the psychiatrist that he did not trust anyone and that the intelligence
agencies at Scotland Yard were ‘stitching him up’. He also said he could not
trust his current solicitor and was asking for a new one. The psychiatrist’s
opinion was that the man had persecutory beliefs, which appeared to be of
delusional intensity. The psychiatrist asked the man whether he had any
suicidal thoughts and he said that he did not know and only God knew. The
man remained on constant watch.
36. On 15 December, the man’s partner visited him. The visit only lasted 15
minutes as they had an argument and the man’s partner left. The man told a
principal officer (PO)he would not be here by Christmas. The man was
extremely paranoid and believed there was a government conspiracy against
him and that he was going to be killed in prison. The PO submitted a Security
Information Report (SIR) recording that information and he updated the ACCT
accordingly. The man spoke to his partner on the phone later that day and
agreed for her and the children to visit the following week.
37. On 17 December, a note in the man’s Caremap (care and management plan)
within the ACCT indicated that the food refusal issue had been resolved. The
man had an ACCT review, which was undertaken by a HCO and a SO. The
man said he felt alright but did get upset when he argued with his partner. He
felt she was trying to make him look bad. The man also maintained
somebody was going to harm him but said he felt safe in the healthcare
centre. He was concerned that police were going to try to ‘stitch him up.’ His
level of risk of self harm was lowered from high to raised.
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38. On 19 December, the man was seen once more by a doctor. The man told
the doctor that the police were trying to kill him. The doctor’s opinion was that
the man had persecutory beliefs. The man said he did not have any thoughts
of suicide or self harm.
39. On 21 December, a note made after the management ward round said that
the man’s referral to a high security unit was discussed, and consideration
was to be given to taking him off constant watch the following week. On 23
December, the man cancelled a visit from his partner.
40. On 24 December, the man had an ACCT review undertaken by a nurse and a
SO. They noted that the man appeared unsettled and remained convinced
that somebody was going to come into his cell and try to kill him. The man
said he did not have any thoughts of self harm.
41. On 26 December, the man asked to have a table in his cell. A request was
made by a SO for the man to have a cardboard table. This was agreed by the
duty governor.
42. On 27 December, the man was reviewed by the psychiatrist. He told the
psychiatrist that he still believed his life was in danger. The psychiatrist made
a referral to the secure unit by faxing the completed referral form. He also
sent a detailed covering letter to the secure unit with the referral. The man
told the psychiatrist that he had spoken to his partner on Christmas Day and
had no concerns about her. The man still believed that he was going to be
killed. A PO noted that the man ‘snapped’ a CD during the night and
threatened to use it. All CDs were removed from his cell, pending a revised
cell sharing assessment. On 28 December, constant watch was stopped on
the psychiatrist’s advice and the man was placed in a single cell on
intermittent watch. The psychiatrist noted in the medical record the man had
eaten and agreed with the plan to relocate him to a single cell.
43. There is an entry in The man’s ACCT by an officer dated 27 December which
says:
“On several occasions we had sensible conversations but when he thinks
no one else is listening he says inane things like, ‘what time are they
coming for me’ and ‘have I got time for a sleep before we go’. He also
wants to know what I am writing in the log or ACCT before coming to the
cell door and saying something idiotic. I haven’t seen any indication of
intent to self harm but I have seen a lot of signs of attention seeking.”
44. There is another entry by the officer, dated 28 December, which says:
“He seems to thrive on people thinking he is paranoid. He even asked me
if I thought he was paranoid and did not seem impressed when I told him I
didn’t. I have seen many prisoners attempt to fake madness and the
man’s is one of the most unconvincing I have come across.”
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45. On 29 December, the man saw the psychiatrist with a nurse. The man
refused to leave his cell. He discussed a letter he had received from his
partner in which he said she had written, ‘You will know where you stand next
year.’ He said he doubted the letter was from his partner and interpreted this
as a reference to him not being alive next year. The man said he was going
to be beaten up and ‘hung drawn and quartered’ before the New Year. He
denied any suicidal intention. The psychiatrist instructed that the man
continue to be monitored on intermittent watch in a single cell and staff were
to observe his food and drink intake. The psychiatrist discussed medication
with the man again, but he said he did not need any.
46. On 2 January 2007, the man told the psychiatrist that he believed his family
and friends along with the secret services were involved in a scheme to kill
him. An ACCT review was held by a nurse and an officer. They noted that
the man believed he was going to be taken to the segregation unit. He feared
that he would be beaten and killed by Intelligence Services. He was
convinced his family and friends were involved. He was not eating much, and
only drinking milk. The man said he was not going to kill himself but was
convinced somebody else was going to kill him. On 3 January, there is a note
in his medical record that he had been picking the wound on his scalp which
had become locally infected. He was prescribed an antibiotic.
47. On 4 January, at a management round meeting it was noted that there was no
change in the man’s mental state and that he had ‘unshakeable persecutory
beliefs.’ He was reviewed by the psychiatrist, and the man now said he was
going to be killed before his trial on 29 January. The man said he had been
‘beaten up’ by the security service, MI5. He believed that his partner and
others were behind this.
48. On 5 January, the man had a visit from his partner. The man told the
psychiatrist after the visit that his partner was trying to kill him, although she
denied it. On 8 January, The man was reviewed by a doctor. The man said
he was going to be killed and he told the doctor that the IRA might have
something to do with it. The man denied any connection with the IRA but
said, ‘They want to blame me as an informer and link me to the peace
process.’ He told the doctor that he believed he had been ‘set up’ over the
past two years and his partner had been involved in that. The man said he
had been bugged and had been under surveillance for years. He believed the
case had been reported in national newspapers in Ireland when he was
arrested and the IRA had seen those.
49. The doctor wrote in the review of the man’s mental state that the man
remained preoccupied with persecutory paranoid delusional beliefs. The man
believed there was a conspiracy against him and he thought he had been
bugged. The doctor also noted that the man had poor awareness of his
current illness. The man had taken Diazepam 10mg twice daily for the past
two days but he had only been partially compliant with taking his medication
previously. On 8 January, the man had an ACCT review by a healthcare
worker, and an officer. The man still believed he was going to be killed in his
cell although he said he did not have any suicidal or self harm ideation.
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50. On 9 January, the doctor wrote to a Crown Court about the man:
“In terms of forthcoming trial, it is overall my opinion that he is fit to plead
and stand trial. Despite having a mental illness he understands the nature
of the charges, could give evidence and follow proceedings … If possible I
would suggest that some consideration should be given to delaying
proceedings until he has been assessed further and most likely in
hospital. My own view is that he is likely to show a good response to
treatment.”
51. On 12 January, the man was seen by a specialist registrar from the secure
unit. The registrar’s opinion was that the man was acutely psychotic and
needed to be transferred urgently to a high security hospital under section 48
of the Mental Health Act. On the same day the man had an ACCT review
which was undertaken by senior healthcare officer (SHCO) and a nurse. The
man did not have any thoughts of suicide or self harm but still believed
somebody was going to kill him. The level of risk of self harm was now
reduced from raised to low.
52. On 15 January, the man was seen by the psychiatrist. The man asked about
his transfer to hospital. The psychiatrist told him that if he got better he would
not have to go to hospital. The man said he wanted to start mixing with other
prisoners and wanted to go onto the ward. He did not want to go to hospital.
The man denied any deliberate self harm/suicidal thoughts or intention. He
repeatedly wanted reassurance from the psychiatrist that he would still be in
prison the next day and would not be transferred to hospital. The man started
taking his antipsychotic medication, Olanzapine.
53. On 16 January, the man was seen yet again by the psychiatrist. The man
repeated that he wanted to move to the ward. He said his partner was due to
visit him later that day but he had cancelled the visit. The man denied any
deliberate self harm or suicidal intention and said he would do anything to get
better. However, the psychiatrist noted that ultimately the man would not
accept that he was ill. The man said he would attend exercise and
association and the psychiatrist agreed to discuss him attending the Cass Unit
with staff there. The plan was for the man to continue taking Olanzapine and
his evening dosage of Diazepam was reduced from 10mg to 5mg. Following
the psychiatrist’s review, the man was transferred to the ward.
54. On the next day, the man was seen by a nurse, who noted that the man
appeared to have settled on the ward, ‘Remains calm, fairly pleasant on
approach. Compliant with his prescribed medication. Eating and drinking
well, no evidence of any suicide or self harm attempt.’ The man’s weight was
64kg, compared with 66kg on 3 December.
55. On 19 January, an ACCT review was undertaken by a nurse and a SHCO.
They noted that the man had not made any attempts at self harm and was
eating better. They recorded that he still had thoughts of self harm but denied
any current plans. The man continued to think that he would be killed by
15
someone. The man was seen by the doctor. He told the doctor that he had
been ‘set up’ and was in danger from the IRA and the peace process was
ultimately in jeopardy as a result. The man accepted his medication but said
he did not want to go to hospital. The doctor spoke to the registrar from the
secure unit, who told him that a decision was being made on the man’s
suitability to go to a medium secure unit.
56. On 21 January, the man was seen by a nurse. The nurse noted that the man
seemed stable in mood, was less paranoid and was eating and drinking. The
man was also taking his medication. The following day, the man was seen by
the doctor and the psychiatrist at the man’s request. The man said he felt he
was ready for his trial and was going to plead guilty. He said he felt better
since being located in the ward and the thoughts of being killed in prison were
not as frequent as before. The man said if he was still around on 29 January,
the date of his trial, he would agree that he was wrong and would apologise to
the doctor and the psychiatrist for wasting their time. The man said he did not
want to go to Broadmoor, and if he did have to go he would stop eating and
drinking. The psychiatrist and the doctor concluded that there appeared to be
some improvement in his mental state.
57. On 23 January, the man was seen by the psychiatrist. The man told the
psychiatrist that he was keen to continue taking Diazepam. The man had a
visit from his partner that afternoon. The psychiatrist lowered the daily
dosage of Diazepam from 10mg to 5mg, morning and evening. The man was
to continue taking Olanzapine. He appeared anxious.
58. On 25 January, the man was discussed during the management ward round.
The impression was that he appeared settled in the ward and the plan was to
continue to review him.
59. On 26 January, the man had a meeting with his co-defendant to discuss their
impending court appearances. There is a note in the man’s medical record by
a nurse that the man appeared fairly settled and was interacting appropriately
with staff and other prisoners. He also noted that the man was eating and
drinking well and there was no evidence of any deliberate self harm or suicidal
intent.
60. On 28 January, there is a note in the man’s medical record by a nurse,
‘Appears brighter in ward, attended exercise and association. Eating and
drinking well. No evidence of deliberate self harm or suicidal intent.’
61. On the next day, the man attended Crown Court. The man pleaded guilty.
On return to prison, there was no change in his category A status. He
returned to the healthcare centre in Belmarsh to await sentence. The man
went back to Crown Court on 30 January. On return, he went back to the
healthcare centre.
62. On 31 January, an officer saw the man. She noted in his history sheet that
there were no problems to report and he was settled in the ward. The officer
16
also recorded that the man was attending exercise and association and was
polite towards staff.
63. The man was reviewed by the psychiatrist. The man told the psychiatrist that
he had pleaded guilty at court on 29 January and had been told that he would
probably get a ten year sentence. He said he had pleaded guilty because he
believed the police and intelligence agencies were against him and his partner
had set him up. The man said he could not trust anybody and still maintained
that he would be killed in prison. The man said he felt calmer since he had
been taking his medication. He was still paranoid and said his partner had set
him up and she was having an affair. He said he had a fair idea who with but
would not tell the psychiatrist. The man added that he was going to stop
eating and drinking to starve himself to death. The man also said he was
going to stop taking his medication from the next day. He said he had been
suffering from pains in his stomach for two days but was not constipated, was
eating and drinking and did not feel nauseous. The man appeared fixed in his
persecutory belief and his desire to starve himself. He discussed his
concerns with healthcare staff and the plan was to continue to review him.
The man had an ACCT review completed by a nurse and a SHCO. They
noted that the man seemed settled, and had not attempted to self harm. The
man told them that he had pleaded guilty at court, and was awaiting sentence.
The man said he might start to refuse food and fluid but he was eating and
drinking sufficiently. He did not express any current thoughts of self harm.
64. On 1 February, the secure unit registrar wrote to a doctor and the psychiatrist
regarding the assessment he had undertaken on 12 January:
“It appears that the man may be suffering from a first onset paranoid
psychotic episode with a possible underlying depressive aetiology or co-
morbid depressive illness. In my opinion he is not fit to plead and stand
trial currently as he has delusional persecutory beliefs regarding his legal
representation and his ability to understand and follow trial proceedings
would most probably be significantly impaired due to his current poor
concentration and attention. If he once more becomes unwilling to
voluntarily take anti-psychotic medication (I understand he started to take
anti-psychotic medication on 17 January) or there is no significant
improvement in his mental state I feel that he would be appropriate for
urgent transfer and treatment in hospital under the provisions in section 48
of the Mental Health Act … As we discussed, if there is no improvement in
his mental state I would be more than happy to review the man and refer
him to the appropriate high secure service.”
65. Also on 1 February, the man was discussed during the management ward
round. Staff were to monitor his food and fluid intake. The psychiatrist
reviewed the man. The man told the psychiatrist he had eaten some
cornflakes and had a cup of tea, but had not eaten any hot food or lunch. The
man said he was going to stop taking his medication as it was causing pains
in his stomach at night. The plan was to continue to review him and for a
doctor to see him about the stomach pains. (There is no evidence that he did
in fact see a doctor about the pains in his stomach.)
17
66. On 5 February, the psychiatrist and a healthcare worker saw the man. The
man told them that he had stopped eating and drinking three days previously.
He said, ‘I can’t wait for my people any more. I am going to do it myself.’ The
man was tearful during the review. He asked the psychiatrist if he would put
him on a drip if he continued to starve himself. However, he told the
psychiatrist later that he had eaten something on 3 February and had eaten a
cake on 4 February. The psychiatrist noted that the man had refused
Olanzapine for three days but had accepted it the previous night and had
asked for sleeping tablets during that time. The man told the psychiatrist that
he had been passing urine that was dark.
67. The psychiatrist tested a urine sample which was negative for ketones which
are present when a person is starving. The man was convinced his partner
was dead and he told the psychiatrist that his partner had told him their
children were not his. The psychiatrist noticed that the man’s tongue was dry
but he was alert and appeared physically well. The plan was to continue with
medication, to encourage him to eat and drink, continue on intermittent watch
and to liaise with the registrar about the referral to the secure unit.
68. On 6 February, an officer saw the man again. She noted that the man
appeared to be more settled and was still attending exercise and association.
She also noted that he helped to keep the ward tidy, spent a lot of time on the
phone to his partner and was polite towards staff and other prisoners. The
psychiatrist also saw the man. The man told him that he had been to court
that day and said it was part of the plot as he had not been asked to give
evidence. The man spoke about his partner and said she had been killed and
was making their children lie to him. The man said he had two cups of tea
and a glass of water that day but was not going to eat or drink any more. He
was still worried that he would be killed in prison or in Broadmoor. The man
asked for more Diazepam and the psychiatrist said he would prescribe more
Diazepam if the man continued to eat and drink. The man denied any suicide
or self-harm intentions but was adamant that he was going to stop eating and
drinking. However, the man agreed to eat and drink when he left the interview
with the psychiatrist. The psychiatrist sent a letter to a Crown Court which
said:
“The man was seen by specialist registrar on 12 January 2007. He was of
the opinion that the man is acutely psychotic and needed urgent transfer to
hospital. The registrar was of the view that the man will need to transfer to
Broadmoor Hospital and we are currently awaiting assessment from
Broadmoor Hospital.”
69. On the same day, the man told a SO that he had asked his legal team to
compile a living will. This is recorded in the ACCT. The SO told my
investigator that he could not recall much about it but did recall that the man
had spoken to his solicitor at length about a living will.
70. On 7 February, the man went to the Cass Unit. Initially he was reluctant to
stay there and asked to go back to the ward. He was persuaded to stay and
18
have a cup of coffee although he had said he was not eating or drinking. He
played Scrabble for just over an hour. At the end of the session the man said
he would soon go to either heaven or hell and maintained that he did not feel
safe. The man said he did feel safe in the ward and in the Cass Unit but that
was because he knew the people there.
71. On 8 February, the man was discussed during the management ward round.
He was assessed as being stable although still a bit up and down. On 9
February, an ACCT review was undertaken by a nurse. The nurse noted that
the man was eating and drinking small amounts. He denied any current
thoughts of self harm, and believed somebody else would harm him. The
nurse noted that the man was attending the Cass Unit and was going to
exercise and association. The man’s weight was stable at 64kg.
72. On 10 February, an unscheduled ACCT review was undertaken by a nurse
and an officer. The man’s review was not due until 19 February, but he was
seen early due to the death of another prisoner. The man remained paranoid
and believed somebody was going to kill him. He denied any suicidal intent
and was eating and drinking small amounts.
73. On the next day, the man was seen by a nurse who noted that the man
appeared settled throughout the day and was eating and drinking well. There
was no evidence of suicidal or self-harm intention. On 14 February, the man
went to the Cass Unit where he engaged in group work and interacted well
with others. It was noted that he did express some feelings of paranoia.
74. On 15 February, the man was discussed again during the management ward
round. It was noted that the man was still paranoid but overall he appeared
settled. The doctor also saw the man. The man told the doctor that he had
cancelled a visit with his partner. He said he was very scared of what was
going to happen to him. He told the doctor that his partner had visited him
‘the other day.’ The doctor tried to get the man to think about other things.
The man was taking his medication but he said he was not eating and could
not see a way forward. The man told the doctor that by not eating he would
die quicker than being tortured. The man was concerned about his partner’s
fidelity and still maintained that he was going to be killed. He feared that he
would be killed by the time peace talks were concluded in Northern Ireland.
The doctor wrote to the Crown Court:
“The man was assessed by a specialist registrar from medium secure unit.
The registrar informed me that he agrees with our diagnosis but in view of
security concerns he could only be safely managed in a high secure
hospital, he has therefore made a referral to Broadmoor. I would ask the
court therefore to delay sentencing until this assessment can be facilitated.
Regrettably beds in secure settings are in short supply and the process
can take some time. I would ask for an initial adjournment of some four
weeks. I would be happy to attend court for further explanation if this
would be of help. My apologies once more for any delay to the
proceedings. Our view overall is that the man should receive treatment
and assessment in hospital.”
19
75. On 16 February, a SHCO noted in the man’s history record, ‘Remains in ward,
attends exercise and association, polite towards staff, no management
problem.’
76. On 19 February, a SHCO and an officer conducted an ACCT review. They
concluded that the man still appeared guarded with paranoid thoughts that
people wanted to kill him. However, he continued to say he had no intention
of killing himself. He was eating and drinking, and attending exercise,
association and the Cass Unit.
77. On 21 February, the man was seen by a nurse who noted that he remained
settled in mood, had good interaction with others and was eating and drinking
well. The man was also seen by a doctor at the man’s request. The man told
the doctor that he had woken up with nightmares and his delusions persisted.
The plan was for the man to be reviewed and his medication was to continue.
78. On 22 February, the man was discussed during the management ward round.
It was noted that he was waiting to be assessed to transfer to a high security
hospital (Broadmoor).
79. On 23 February, the man was seen by a nurse. The nurse noted that the man
was still paranoid. She also recorded that he was anxious and complained of
nightmares. However, he was compliant with treatment, was eating and
drinking and denied any current thoughts or plans to self harm.
80. The man’s partner phoned the prison on 23 February 2007.. The man’s
partner told an officer that she was upset as the man had told her that he had
not been seen by a doctor and felt the doctor was avoiding him. The man had
said he thought his life was in danger and he was convinced he was going to
be killed if he was sent to the houseblock. The man’s partner told the officer
that the man had met with his co-defendant before the trial and as a result the
man had become more paranoid. According to the man’s partner, the co-
defendant had told the man the police were looking into his case and that he
could face further charges.
81. The man was due back in court on 16 March. He told his partner he could no
longer face her visiting him. The officer reassured the man’s partner that if he
needed to see a doctor that would be arranged. The officer also indicated
that the man had not seen his co-defendant since their last court appearance.
82. On 24 February, the man’s partner phoned the prison to cancel her visit. On
27 February, a SHCO noted in the man’s history record, ‘Remains in ward
conditions. Final case review. Closed ACCT after an improvement in his
general condition. Interacting well with both staff and inmates. No
management problems to date.’
83. On 27 February, a final case review was completed by the SHCO and a nurse
and the ACCT was closed. The notes of the review say that the man was:
20
‘nervous and anxious, asking for a single cell. Eating and drinking ok.
In contact with his family, although declining visits with them as he
feels scared. Last incident of self harm November 2006. Attends
association, no thoughts of harming himself, still feels others are going
to harm him. No recent attempts of self harm.’
84. Shortly after the man’s review, the nurse completed an ACCT review for
another prisoner. This prisoner told the nurse that she did not need to worry
about him but she should be concerned about the man. The nurse told my
investigator that she went to see the man after the other prisoner’s review and
asked him how he was. The nurse told the man that another prisoner had
expressed concerns about him. The man told her again that he was fine. The
nurse did not note this information anywhere in the man’s record.
85. On 28 February, a doctor reviewed the man. The man was still paranoid and
said he thought that MI5 would try to kill him. He said he did not feel suicidal.
The doctor concluded that the man was paranoid but was not suffering from
hallucinations. The man asked for his medication to be reviewed but he still
believed he was going to be killed.
86. On 1 March, the man was discussed during the management ward round. It
was noted that he was still paranoid and his medication was confirmed. The
man was reviewed later by a doctor who recorded that the man was still
paranoid. The man asked for an increase in his medication and to see
another doctor. This doctor prescribed an increased dose of Olanzapine
(from 10mg to 15mg).
87. On 2 March, the man was seen by the doctor. The doctor told the man he
thought going to the houseblock would be bad for his health. The doctor’s
opinion was that the man misinterpreted this. The man was concerned for his
own wellbeing. The man wanted the doctor to speak to his partner to
reassure her that he was alright. The doctor spoke to the man’s partner and
tried to reassure her of his wellbeing.
21
EVENTS ON 3 MARCH
88. The man was located in ward 3 with five other prisoners as per attached
diagram (Annex 1). On 2 March, two officers a nurse and another staff
member were on night duty. An officer, the nurse and a staff member were in
charge of checking prisoners in the healthcare centre throughout the night.
The second officer was carrying out constant observation on a prisoner. Two
of the prisoners in ward 3 were on ACCT documents and would have required
regular checks. (Staff on duty during night patrol take it in turns to check the
prisoners within the healthcare centre throughout the night, although my
investigator found that there is no standard procedure for doing this.)
89. On of the officers explained to my investigator that he normally completes
checks at the beginning, middle and end of the night shift. Checks on ward 3
are made by looking through the main window of the ward, which gives a view
of four beds (beds one to four in the diagram). The other two beds are
observed through the windows of the doctor’s office next to the ward (beds 5
and 6 in the diagram). The man was located in bed 5, close to the external
windows of the ward. The officer aid that the last visible check he made on
ward 3 was at 3.10am on 3 March. The officer noticed nothing untoward
when he checked at that time. The next check he was due to complete was
at 5.45am.
90. At around 5.30am, the nurse was in the doctor’s office making up medical
records. The nurse heard shouting and somebody banging on the main
window of ward 3. The nurse left the doctor’s office and saw a prisoner
banging on the window and shouting. He looked into the ward and saw two
prisoners trying to support the man. The man had made a ligature from a
piece of bed sheet which was attached to the window behind his bed. The
nurse immediately called for help from the officer and staff member then
called for further assistance on his radio.
91. The officer broke his sealed pouch containing keys for ward 3 and entered the
ward with the nurse and member of staff. (On night patrol officers carry cell
keys in a sealed pouch; they are only to be used in an emergency.) The
officer and member of staff supported the man whilst the nurse went to the
staff office opposite ward 3 to get the ligature scissors to cut the ligature.
Meanwhile, the officer pulled the ligature apart as it was too tight to cut off and
the member of staff checked for vital signs. There were none.
92. By the time the nurse returned, the man had been laid on the floor and the
member of staff and the officer had commenced cardiopulmonary
resuscitation (CPR). The staff member commenced chest compressions
while the officer ensured that the man’s head was tilted backwards and his
airway was clear. The nurse collected oxygen and the emergency
resuscitation bag from the clinical room. The member of staff attached the
oxygen mask which the officer held in place. A PO (the night orderly officer)
arrived and saw the nurse, the officer and the staff member giving CPR.
Another officer also arrived at the ward and relieved the officer from the
constant watch he was doing. This officer and the nurse then collected the
22
defibrillator from the defibrillator cupboard in the corridor. A third officer
arrived and helped the nurse move the other prisoners from the ward to the
association room. An ambulance was called at 5.40am and arrived at
5.47am. A second ambulance arrived at 5.54am. The first paramedics
continued with CPR and the man was taken to hospital. The ambulance left
the prison at 6.20am. The man was later pronounced dead at 6.34am.
93. Prisoners in the healthcare centre were immediately offered the support of
Listeners (prisoners trained to offer peer support) and Samaritans. ACCT
case reviews were undertaken for all prisoners in the healthcare centre who
were being monitored.
94. Staff involved were supported immediately by staff care and welfare and were
offered Samaritans’ support.
23
ISSUES
Family concerns
95. The man’s partner and her solicitor raised various concerns. The man’s
partner asked why staff had not removed the chair that the man kept trying to
stand on in his cell. As I have noted, The man’s table and chair were
immediately removed from his cell on 25 November. The table was replaced
by a cardboard table on 26 December.
96. The man’s partner was also concerned that the man’s change in behaviour
had come ‘out of the blue’ on 25 November. Prior to this episode of serious
self-harm there had been few entries about the man and those recorded were
positive comments, including his willingness to help with cleaning. The
solicitor said he had seen the man in September 2006 and had been
concerned about his mental health at this time. There is no documentation
suggesting this concern was raised with prison staff.
97. In his police statement, a prisoner says that he was aware that the man had
tied shoelaces and a piece of bed sheet in various knots a few days before he
died. The prisoner said that the man had put these in a locker. The prisoner
said he took the shoelaces from the man and placed the piece of bed sheet in
a bin. The prisoner did not tell any member of staff about the incident.
98. The man’s partner felt the man was showing clear signs of stress and
agitation. She said that, prior to his death, she had been concerned that the
man had appeared uncharacteristically calm and informed the doctor. The
man’s partner felt in hindsight this seemed an obvious sign of his intention to
take his own life. She questioned why this was not picked up by healthcare
staff. She was also concerned about the comment the doctor made to the
man that returning to the houseblock would be bad for his health. The doctor
felt that her partner had, unfortunately, misinterpreted this. The man’s partner
questioned the suitability of such a comment, given her partner’s state of mind
at this time.
99. The solicitor stated his strong concern about the difference in the psychiatric
reports produced by the doctor and the specialist registrar about whether the
man had been fit to plead. The doctor had agreed he was fit to plead,
however, the registrar deemed the man unfit to plead. The solicitor thought it
should have been standard practice to refer this decision further if agreement
could not be reached. In its clinical review, the PCT say:
“In relation to fitness to plead. Firstly there was a time delay of one
month between the assessments which may have accounted for a
difference. (the doctor’s report was dated 9 January 2007 and the
registrar’s report was dated 6 February.) However, fitness to plead is a
matter of clinical opinion and differences in opinion may well arise. Our
understanding is that where differences of opinion arise then this is a
matter for the court to decide which opinion they wish to take.”
24
100. The solicitor questioned the independence of the clinical review as the local
PCT have responsibility for healthcare services at Belmarsh. The solicitor
believed that psychiatric opinion was crucial in determining the care the man
received whilst in custody, and felt strongly that an independent psychiatric
opinion was needed to assess the quality and appropriateness of the man’s
treatment. The PCT advise:
“The review team consisted of two doctors and one lay person. None
of the team were employees of the PCT but were paid by the PCT for
their time in completing the report. The report was discussed by a
multi-agency panel including representatives of Belmarsh and the PCT
and some minor changes were made to the final report as a result.
The report, however, is an independent statement of the review of the
man’s care by the review team.”
I agree that the clinical review constitutes an independent assessment of the
man’s clinical care while in Belmarsh.
Clinical care
103. Guidelines for dealing with prisoners with mental health problems in prisons
are set out in the document, Mental Health Observation, including Constant
Observation: Good Practice Guidelines for healthcare staff working in prisons,
Gateway Reference: 7003 (HM Prison Service and Department of Health) and
Prison Service Order (PSO) 2700. One of the critical issues to consider is the
prisoner’s location. Initially, the man was located in a gated cell on constant
observation. He was then located in a single cell on intermittent watch, and
finally he was located in ward 3, a six bed ward. PSO 2700 states:
“Constant observation can only be authorised by a doctor or nurse (in
consultation with the duty governor) or the duty governor (in
consultation with a doctor or nurse) … Prisoners placed under constant
observation should be urgently referred for mental health assessment.
Their case must be reviewed as soon as is practicable, and certainly
within 4 hours (or immediately prior to unlock the following morning in
cases where the prisoner is placed under constant observation during
the night) and every 4 hours thereafter for the remainder of that
establishment’s core working day. In those exceptional cases where
this level of crisis lasts beyond 24 hours, further case reviews must be
held at least three times during that establishment’s core working day.
Acute suicidal crisis is usually temporary and the aim of the case
reviews should be to reduce the level of supervision progressively as
the prisoner’s condition improves. The temporary nature of this level of
supervision must be reflected in the support plan.”
104. I consider the man’s location within the healthcare centre at various stages to
have been appropriate. On each occasion the decision to relocate was made
by the psychiatrist and was clearly documented in the medical record. I am
concerned, however, that this was not documented clearly in the ACCT.
25
The Healthcare Manager should ensure that, when a prisoner is
monitored on ACCT, staff clearly document important information such
as decisions to relocate in the ACCT form as well as in the medical
record.
105. The process for referring the man for an assessment for transfer to a
psychiatric hospital was initiated on 27 December 2006 by the psychiatrist.
The man was assessed by a specialist registrar from a medium secure unit on
12 January 2007. That assessment concluded that the man should be
assessed for transfer to a high security unit. The clinical review concludes
that:
“The Forensic Service were involved and undertook timely assessment
and supported the recommendation that hospital care was appropriate.
His category A status meant that there were substantial delays in
achieving this. He was awaiting assessment by Broadmoor. These
delays are inherent in the referral system itself and did not relate to any
actions taken within Belmarsh.
“For his mental health The man was reviewed regularly and
appropriately to a greater extent than that expected in the community.
In the community he may have been sectioned as he was non
compliant with his medication at times and very paranoid.”
106. The man complained of stomach trouble and it was noted that he lost a
significant amount of weight. There seems little evidence that beyond the
health screen at Wormwood Scrubs, and attendance at A&E for his head
injury, there were any other checks or investigations of his physical heath.
His significant weight loss was noted on more than one occasion and the
man’s food and drink refusal was monitored. His weight loss, however, was
not investigated for physical causes. Possible physical causes for his
paranoia were not investigated. The clinical review concludes:
“We would expect that outside a prison in a primary care setting he
would have been offered a physical health check and investigations of
his weight loss would have taken place. Physical health reviews are an
established part of the National Service Framework (NSF) standards.”
The Healthcare Manager should ensure that any action regarding a
patient’s care is taken forward appropriately and in a timely fashion to
provide a more holistic approach to care to ensure all the patient’s
needs are met.
Despite this, I was impressed overall by the continuity of care given to the
man within the healthcare centre.
26
ACCT management
107. The man was managed on an ACCT from 24 November until 27 February.
Apart from the incidents of self harm on 24 and 25 November he did not
indicate that he intended to self harm. The man was paranoid that others
would kill him but did not express any suicidal intentions. I am satisfied
therefore that it was appropriate to close the ACCT on 27 February.
However, I am concerned that the ACCT was closed without input from
psychiatrist services (that is the psychiatrist and the doctor) considering the
close supervision he already had from them. The clinical review says:
“In the ACCT guide it states that key people should be involved in case
reviews. This should be particularly an issue at the point of closure.
Where the Psychiatric team has continued significant involvement in
the patient’s management, it is appropriate to discuss the potential
closure with the team prior to prison staff undertaking the case review
and closure procedure.”
This issue has been mentioned in another of my investigations at Belmarsh,
the final report for which was issued in January 2007.
The Healthcare Manager should ensure, as a matter of urgency, that all
staff are aware of the guidance for completing ACCT case reviews. Key
people who have continued and significant involvement in the
prisoner’s care should be involved in case reviews.
108. A prisoner told a nurse that he was worried about the man. The nurse said
she spoke to the man about the prisoner’s anxieties and the man said he was
fine. I am concerned that the nurse did not make a note of this anywhere in
the man’s medical record or ACCT. A similar issue has been raised in
another of my investigations at Belmarsh, the final report for which was issued
in November 2007.
The Healthcare Manager should ensure that staff make a note of
important information in relevant documentation such as the ACCT form
and the medical record to ensure continuity of care.
109. The entries in the man’s ACCT form by an officer dated 27 and 28 December
2007, are unfortunate and inappropriate and based on inexpert opinion.
Entries in the ACCT must be meaningful and include relevant information on
the person’s mood, behaviour and situation. However, I do not make a
recommendation, other than to draw this to the attention of the Governor, as
other entries are appropriate and include significant information as required.
110. Observation of patients in ward 3 was difficult. Due to its position, there was
no complete view of the bed that the man occupied. The bed was in the
corner of the ward in a recess and the healthcare centre is dark, particularly
during the night. The only place to view the bed is through the window of the
doctor’s room next to the ward. A bright light was put on to check on
prisoners which was disruptive when prisoners were trying to sleep. I agree
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with the conclusion of the clinical review that all prisoners on the healthcare
unit should be in a bed that is clearly visible to healthcare workers.
111. I am pleased that changes have been made to ward 3 since The man’s death.
Lighting in the ward is now controlled by a dimmer switch which can be
regulated to light the ward in sections. This makes it easier to check on
prisoners during the night. The prison is also looking at implementing other
measures, such as a buzzer system to indicate when prisoners go into the
recess, as well as looking at camera positioning. In addition, the furniture in
the recess has been re-designed as an anti-ligature measure. Glass windows
in the ward are to be replaced, as they are scratched and discoloured, making
it difficult to see through when observing. Finally, a cupboard in the doctor’s
room next to the ward that does not allow staff to get close enough to the
window to have full observation is going to be moved.
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RECOMMENDATIONS
The Healthcare Manager should ensure that, when a prisoner is monitored on
ACCT, staff clearly document important information such as decisions to
relocate in the ACCT form as well as in the medical record.
The Healthcare Manager should ensure that any action regarding a patient’s
care is taken forward appropriately and in a timely fashion to provide a more
holistic approach to care to ensure all the patient’s needs are met.
The Healthcare Manager should ensure, as a matter of urgency, that all staff
are aware of the guidance for completing ACCT case reviews. Key people who
have continued and significant involvement in the prisoner’s care should be
involved in case reviews.
The Healthcare Manager should ensure that staff make a note of important
information in relevant documentation such as the ACCT form and the clinical
record to ensure continuity of care.
Comments following the draft report:
Factual inaccuracies:
Paragraph 31 has been amended to reflect the correct title of Charge Nurse
rather than Nurse.
Paragraph 31 has also been amended to reflect that Charge Nurse completed a
secondary health screen for the man and not a well man check.
The Prison Service has accepted the recommendations apart from the second
one which has been partially accepted. The Action planned is attached.
At the close of the consultation period, the solicitors acting on behalf of the
man’s partner informed my office that they were not in a position to provide
any comment on the draft report. The solicitors declined additional time to
respond and explained that it was their intention to instruct their own expert to
advise on the medical issues, once they were in a position to do so, in order
that their client’s concerns could be appropriately addressed at the Coroner’s
inquest.
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