Individual at Bristol

Investigation into the circumstances surrounding the
death of a man at HMP Bristol
in October 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2009
This is the report of an investigation into the death of a man who was found in his
cell with a ligature around his neck at HMP Bristol on 14 October 2007. The man
was on remand for Theft Act offences. He was 27 years old.
I wish to offer my sincere sympathy and condolences to the man’s family and friends
for their loss.
This investigation was conducted by two of my investigators. I would like to thank
the Governor of HMP Bristol and his staff for their help and co-operation during this
investigation. I also wish to thank the prisoners who agreed to be interviewed.
The Bristol Primary Care Trust appointed a clinical reviewer to undertake a review of
the medical care the man received whilst at Bristol. I am grateful for his report which
is annexed to this investigation report.
The man had suffered the loss of his step-father in 2005, and the deaths of his
mother and father within months of each other in 2007. His mother’s death was
particularly traumatic, causing him to suffer from hallucinations and hear her voice.
He received a significant level of support from the prison’s mental health team and
visiting psychiatrists. Unfortunately, two days after his father’s funeral he apparently
took his own life.
The man emerges from my report as a very sad and vulnerable man. His treatment
by HMP Bristol included some very good aspects, but I have also found flaws in the
ACCT process and a failure to share information about risk.
I have made eight recommendations which have all been accepted by the prison
service and formally identified an example of good practice on the part of one of the
officers who first attended to the man.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2009
2
CONTENTS
Summary 4
The Investigation Process 5
HMP Bristol 7
Key Findings 9
Issues 24
Recommendations 30
3
SUMMARY
The man was charged with offences under the Theft Act and remanded into custody
on 22 June 2007, arriving at HMP Bristol the same day. During the reception
process, he was identified as having a substance misuse problem and referred to the
substance misuse doctor. The man was put on a ten day subutex detoxification
plan. He was not referred for a mental health assessment as he should have been.
As the result of a referral made by a Counselling, Assessment, Referral, Advice and
Throughcare (CARATs ) drugs worker, the man was seen by a consultant
psychiatrist, on 31 July. The consultant psychiatrist diagnosed significant depressive
illness with marked anxiety and agitation related to the death of the man’s mother.
Although the man admitted to suicidal thoughts, an Assessment, Care in Custody
and Teamwork (ACCT) document was not opened at that time.
However, an ACCT was opened four days later on 4 August 2007 by one of the
prison doctors, as the result of reading the psychiatrist’s report and talking with the
man. Two days later the man smashed his television, cut his hand and tried to bite
an officer. The man began to talk about seeing his dead mother in his cell and being
told by her to kill someone to bring her back to life. The man was assessed by a
nurse from the mental health team and continued to see the consultant psychiatrist.
The man was seen to have a cut on his arm on 17 August, and he was very tearful
and agitated. As he was being led to a gated cell the man handed staff a sharpened
plastic knife that he had been using to self-harm.
On 5 September, the man was assaulted by another prisoner. He returned to
healthcare awaiting a move to D wing (the vulnerable prisoner wing). At the case
review on 12 September it was decided by the staff and the man that the ACCT
should be closed.
The man was told that his father had died on 30 September and another ACCT was
opened. The man was concerned about the pent up emotions he was feeling and
was caught trying to hide his valium in his hand (known as palming) on two
occasions. He explained that he was only intending to save the drugs to use at night
when he would find them more beneficial.
On 6 October, the man cut both his wrists with a piece of glass. He would say to the
consultant psychiatrist that, “I cut my wrists seriously and my cell mate saved my
life.”
The man attended an ACCT review on 11 October. The summary was generally
positive with the man saying that he was looking for closure from the funeral and
then hoping to move on with his life. The next day the man went to his father’s
funeral, telling staff on his return that he was proud of himself for being able to stand
up and talk about his father.
The man was found in his cell at 3.36pm three days later on 14 October with a
ligature around his neck. He was pronounced dead by paramedics at 4.07pm.
4
THE INVESTIGATION PROCESS
1. The investigation was opened by one of my senior investigators, on 23 October
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. My investigator and his colleague, 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.
3. One of my family liaison officers, contacted the man’s sister as his acting next
of kin. She offered the opportunity to meet with her and my investigator to
discuss the purpose of the investigation and to enable the family to raise any
concerns or questions they would like explored or addressed. My family liaison
officer and investigator met the man’s sister and brother at their solicitor’s office
on 27 November 2007. They asked the following questions:
(cid:127) Was a suicide note found and if so what happened to it?
(cid:127) Exactly how had the man died?
(cid:127) Had the man been on a ‘suicide watch’?
(cid:127) How was his mental health being monitored and who by?
(cid:127) Had he been on any medication whilst at Bristol?
(cid:127) Had the man had been given any sedation prior to attending his father’s
funeral?
(cid:127) Why the ACCT observations were reduced from every 15 minutes to
every 30 minutes just two days after his father’s funeral?
(cid:127) Was the man on a detoxification programme whilst in custody?
(cid:127) When had the man previously self-harmed (cut his wrists) and what
action was taken?
4. The solicitor acting for the family also requested advance disclosure of the
relevant prison documentation. It was provided a short time later. I have done
my best to address the questions raised by the man’s family, and I hope this
report helps them to better understand the events leading to his death on the
afternoon of 14 October 2007.
5. 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.
Upon completion, this report will be sent to the Coroner to assist in preparing
for the inquest into the man’s death.
6. Bristol Primary Care Trust was asked to prepare a clinical review of the care
that the man received whilst at Bristol. The Trust appointed a member of the
PCT’s Professional Executive Committee to undertake the review.
5
HMP BRISTOL
7. Bristol is an inner city Victorian prison located in the Horfield area of the city. It
first opened in 1883. It is a category B prison with an operational capacity of
606. There are seven wings with accommodation being a mixture of Victorian
galleried landings and two wings designed in the 1960s. Provision of
healthcare within the prison is the responsibility of Bristol Primary Care Trust.
The healthcare unit has 20 in-patient beds. The man’s location at Bristol is
shown in the table below.
The man’s location at Bristol
22/6/07 B wing
6/7/07 D wing
30/7/07 A wing
4/8/07 Healthcare
4/9/07 G wing
5/9/07 Healthcare
10/9/07 D wing
6/10/07 Healthcare
7/10/07 D wing
9/10/07 D wing single cell
8. Ms Anne Owers, Her Majesty’s Chief Inspector of Prisons, writes in the forward
to her March 2008 short follow-up inspection report of Bristol:
“HMP Bristol is a local prison, holding around 600 prisoners – 26% above its
uncrowded capacity. It suffers from many of the problems associated with
population pressure: 300 prisoner movements a week, some unsuitable
accommodation, insufficient activity spaces and difficulties in resettlement
planning for a transient population. It is a measure of the task facing
managers that, although this inspection did find improvements, the prison
still remained deficient in relation to safety, respect and purposeful activity…
Managers at Bristol had succeeded in reversing the decline we recorded at
the last inspection. As a consequence, we were able to raise two of our
assessments. However, in spite of these efforts, the effects of continued
population pressure meant that Bristol was not yet performing well enough in
three crucial areas – safety, respect and activity.”
9. In her previous report in 2005, Ms Owers had been critical of the mental health
arrangements at Bristol and made a recommendation. In her 2008 report she
writes that the recommendation had been achieved:
“The area manager should commission a review of mental health need
and management, to examine the need for a court diversion scheme,
ensure an integrated health care provision (including day care) and
identify and provide for staff training needs.
“Achieved. Mental health services were provided by the Avon and Wiltshire
Partnership Trust. A senior manager from the Criminal Justice Liaison
Service worked closely with the magistrates’ court and mental health
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providers to ensure that the court diversion scheme worked successfully.
Senior mental health workers were based at the court and carried out
assessments and referrals. They had excellent links with the prison and
ensured that detainees or prisoners attending court were managed
appropriately. Any detainees with a history of mental illness who were
remanded in custody by the courts were seen by the team, and all relevant
information passed on to the prison. It was evident that there was good joint
working between the courts and prison systems.
“Mental health services had improved considerably since our previous
inspection. An in-reach team had been established and two well qualified
and experienced registered mental health nurses provided a high level of
care to prisoners. The team worked well with the primary care mental health
team and there was evidence of good multidisciplinary joint working between
all those involved in the care of prisoners with mental health needs. Access
to professional training for staff was fully supported and provided where
necessary. Mental health awareness training for generic prison staff was
provided through a rolling programme delivered by members of the mental
health team. Day care was now provided.”
10. Each prison has an Independent Monitoring Board (IMB) whose members are
independent and unpaid. They monitor day-to-day life in the prison to ensure
that proper standards of care and decency are maintained. Writing in the latest
IMB report for Bristol (2006-2007), the chairperson says:
“Many in-patients have severe mental health problems. They are often
volatile and need a good deal of care. Avon and Wiltshire Partnership Trust
has been recently appointed to provide mental care provision, which
includes Mental Health Inreach programme, and covers 7 days a week.
New clinics that have been set up within the last year,
(cid:127) In the Single Point Entry Clinic all agencies/ departments meet together to
focus on the treatment plans for individual prisoners.
(cid:127) Depot Clinic focuses on longer lasting medicines for mentally ill patients.
(cid:127) Triage Clinic is held weekly so that all mental health referrals are
prioritised by need.
(cid:127) Secondary Healthcare Screening is now in place for every one who wants
it within 7 days.
(cid:127) Well Man Clinic focuses on obese prisoners looking at exercise and diet.
“Day Care is a busy and thriving department offering counselling and
treatment up to 4 hours per day depending on availability of different skills
and needs of the prisoners.”
11. Since I was given responsibility for investigating all deaths in prisons in April
2004, there have been 12 deaths at Bristol prior to that of the man. Three were
self-inflicted, eight were from natural causes, and one was the result of an illicit
drug overdose. The issues raised in my reports into those earlier deaths are
not relevant to this one.
7
KEY FINDINGS
12. On 22 June 2007, the man was remanded into custody by North Somerset
Magistrates Court for Theft Act offences and taken to HMP Bristol. He had
been in prison and young offender institutions many times before and had been
released from Bristol four months earlier in February 2007.
13. During the reception process the man was seen by a reception nurse who
completed the First Reception Health Screen (FRHC). The man told the nurse
that he had not seen a doctor in the last few months and that he was not
receiving any prescribed medication. He said that he usually drank six or
seven cans of lager each day. When asked about illicit drug use, the man told
the nurse that on a daily basis he used heroin, diazepam and crack cocaine.
14. The man said he had not received treatment from a psychiatrist outside prison,
nor had he been prescribed any medication for mental health problems. He did
admit to harming himself outside prison by cutting his face a “long time ago”.
The man said that he did not feel like harming himself but the nurse recorded
the following on the form: “Says he’s still upset at his mother’s death four
months ago from a heroin overdose. Says he needs to grieve properly.
Doesn’t want to self-harm.”
15. The nurse recorded the man’s pulse as 88 beats per minute and wrote that he
felt sweaty. He was given 135mgs of mebeverine for stomach cramps, 7.5mgs
of zopiclone to help him sleep, 200mgs of carbamazepine to help with alcohol
detoxification and 400mgs of ibuprofen for general aches.
16. The reception nurse referred the man to see a doctor regarding his substance
use and also to the drugs service. He should have been referred for a mental
health assessment as he answered ‘yes’ to the question about self-harm
outside prison, but this did not happen. In her interview with my investigator,
the reception nurse said that she does not know why she did not refer the man
for the assessment, but emphasised that she did not have any concerns
regarding his mental health at the time. The man was allocated a cell on G
wing.
17. The following day, a prison doctor went to see the man regarding his substance
use but he was not in his cell as he had gone to change his clothes. The doctor
wrote that he would see him the next day.
18. The doctor saw the man on 24 June. He prescribed a ten day buprenorphine
(subutex) detoxification plan, which the man completed on 4 July. The doctor
completed an electronic substance use form on 25 June, in which he noted that
the urine sample given to the reception nurse tested positive for
benzodiazepines and opiates. He noted that the man had been using the
drugs during the four months he had been out of prison and that he complained
of insomnia, aches and sweats.
19. On 26 June, the man was assessed by a substance misuse nurse who
completed a detoxification care plan. The nurse asked him when he expected
to be released from prison. The man said that he thought he would be
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sentenced to five years imprisonment when he went to court in three days time.
He told the nurse that he had been using heroin since he was 14 years old and
had spent the majority of the last 11 years in prison. He also said that he had
lost both his parents to heroin and alcohol.
20. On Friday 29 June, the man was taken to Bristol Crown Court and was further
remanded until 28 September.
21. The next day a prison officer wrote in the man’s wing history sheet that he was
always polite on the wing. The one matter of note at that time was that the man
was keen to find work.
22. On 6 July, a second officer saw the man after he had asked to be moved to D
wing. (D wing is the area of the prison where prisoners are housed who are
thought to be vulnerable either due to the nature of their offence or because
they are being bullied or in debt.) The man told the officer that he had been
told to bring a package into the prison on a visit. He had refused and said that
he had been threatened. The man named the two prisoners making the threat.
23. The man was assessed by the second officer, who also completed a Cell
Sharing Risk Assessment (The CSRA is a form used to help staff decide on the
apparent risk a prisoner poses to any other person sharing a cell. There is a
choice of high, medium or low risk.). The officer considered the man as low risk
and moved him into cell 1-23 on D wing. It is clear that the man felt
comfortable talking to the wing staff and that he was supported by an
immediate move to D wing.
24. A third officer gave the man a verbal warning on 14 July. The warning was for
having pictures on the cell wall and ones too large for the picture board. He
was also told about having blankets up at the window. The officer wrote that
the man became confrontational and she told him he would be given an official
IEP warning if he did not act on her advice. (IEP stands for incentives and
earned privileges. If a prisoner gets three such warnings he will be put onto a
basic regime thereby losing gym, association and other privileges.)
25. At 9.45am on 17 July, the man was taken to Weston-super-Mare Police Station
in connection with an investigation into a robbery and a number of burglaries.
He returned to the prison at 3.40pm.
26. On 21 July, the man was expecting a telephone call from his girlfriend, a
prisoner at HMP Eastwood Park, but the call was not made. A fourth officer
contacted the prison to ascertain the reason and was told that the prisoner had
not asked to make a call. The officer gave that information to the man who said
he would write to his girlfriend.
27. A fifth officer spoke with the man on 24 July. The man told her that he felt
things were not going too well and that he had got in with the ‘wrong crowd’ as
a way to fit in. The officer wrote that the man was feeling a ‘bit down’ and they
decided on a plan of action to get him working. The officer also warned him
that his poor behaviour was being watched.
9
28. The man was also seen by a member of the CARATs team, that day. (CARAT
stands for Counselling, Assessment, Referral, Advice and Throughcare.
Everyone coming into prison identified as having a drug problem is assessed,
given advice about their misusing, and referred to other services such as drug
treatment programmes, housing and employment.) The man told the CARATs
worker that he had been prescribed medication for depression a while ago, and
that since being in prison he had not slept much. A mental health referral form
was submitted and the level of urgency was marked as routine. An
appointment was made for the man to see the consultant psychiatrist, a
consultant psychiatrist, on 31 July.
29. On 25 July, the man made an application to see a doctor. He wrote:
“I suffer from bad depression and I would like to see the doctor. So I can get
some help again as things are starting to get really difficult for me again,
thank you.”
30. The man saw a doctor two days later on 27 July. Again he said that he had lost
both of his parents. He also said that he was only sleeping two to three hours a
night and having nightmares. He denied any thoughts of self-harm. The doctor
prescribed the man 20mg of citalopram, an anti-depressant.
36. Three days later on 30 July, the man was moved to A wing at his own request.
The following day the man was seen by the consultant psychiatrist and moved
into the healthcare centre. The man told the psychiatrist that his father had
drank himself to death in 2005, and that his mother had died from a heroin
overdose in March 2007. He said that he was experiencing panic attacks and
paranoid feelings that were getting worse. The man revealed that he had
suicidal thoughts, but said he did not want to kill himself.
37. The consultant psychiatrist’s diagnosis was as follows:
“The man appears to be suffering from a significant depressive illness with
marked anxiety and agitation. This has occurred in the context of
bereavement (his mother died in March) and following a detoxification
regime. He has a strong family history of mood disorder and alcohol and
substance abuse.”
38. The consultant psychiatrist increased the man’s citalopram prescription to
40mg a day and prescribed 50mg of chlorpromazine for agitation and 7.5mg of
zopiclone at night to help with his sleep. He did not open an ACCT document.
In his interview with my investigators, the consultant psychiatrist said this was
because he did not think the man was a high suicide risk. He added that if he
thought someone was suicidal he would recommend that an ACCT was
opened.
39. 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.
10
40. There are entries in the man’s medical record by the doctor on 1 and 2 August
stating that there was no change in the man’s condition. The next day the
doctor wrote: “Rather anxious. Waking at 3am – seeing image of his deceased
mother in his cell. Distresses him. Advised to allow time for citalopram to have
effect.”
41. On 4 August, the man was seen by another doctor who decided after talking to
him to open an ACCT. The observations were to be visual every two hours,
recorded every four hours. In an interview with my investigators, the doctor
explained the reasoning behind his decision to open an ACCT:
“Well because he was very disturbed and I thought his condition to be
impulsive and that his delusion was round about the death of a parent
rather than pink elephants or anything. And so I thought the combination
of the type of delusion he was having, plus [the consultant psychiatrist’s]
assessment, which I’ve written ‘In view of [the consultant psychiatrist’s]
assessment’, so there was the previous consultant’s opinion that he might
possibly be impulsive. The combination of those three factors made me
feel we should open an ACCT, possibly move him to a safer cell. He
wasn’t kept in a safer cell; it was just for a period before he moved out
again.”
42. A senior officer conducted the ACCT assessment interview on 5 August.
Section three of the form asks about any previous acts of self-harm or suicide
attempts, and the man said that he had tried to overdose after his mother’s
death. The senior officer expanded on this in her interview with my
investigators:
“We covered if there had been previous acts of self harm or suicide
attempts and he informed me that in mid-May he had taken an overdose of
heroin and valium because he wanted to be with his mum and he was
actually found but was very unhappy about being revived.”
43. The prison doctor saw the man again on 5 August. He wrote: “Agitated. Try
increasing chlorpromazine to 100mg morning and 50mg in the afternoon.
Working diagnosis – drug induced psychosis.”
44. During the afternoon of 6 August, loud screams were heard coming from the
man’s cell in the healthcare centre. Staff saw that he had smashed his
television and cut his hand. When officers entered the cell the man tried to bite
one of them. The man was restrained and taken to the segregation unit where
he was searched for sharp objects. The man was then returned to healthcare
and put into a gated cell (a cell that has a clear Perspex covered barred gate in
place of the usual solid metal door.)
45. A registered mental health nurse employed by Avon and Wiltshire Mental
Healthcare Trust as a Forensic In-Reach Practitioner, explained in her interview
what happened when the man returned to his cell:
“He was obviously in a stressed and agitated state, so we had a visiting
Psychiatrist coming in that afternoon a Consultant Forensic Psychiatrist
11
from Fromeside Clinic and I asked him to see the man as an emergency.
The man was complaining of hearing his dead mother’s voice, stated that
the reason he smashed the television was that she had appeared on the
television in front of his eyes, so that distressed him so he smashed it. He
admitted that he knew that this couldn’t be true, however it felt real to him
at the time. The consultant forensic psychiatrist’s assessment was that he
didn’t feel that this was a psychotic illness, but he was suffering from an
extreme grief reaction and some withdrawal from illegal substances.
Medication was adjusted and the consultant forensic psychiatrist felt that
the man should remain in the healthcare centre.”
46. The nurse saw the man the next day. He told her that he had heard his dead
mother’s voice and she was telling him to kill someone so that she could come
back to life. At the same time he was aware that the voice was not real.
47. In the afternoon the man asked to see the senior officer. He told her that he
now realised that it was not D wing making him feel low, it was his grief and
anger. He wanted to leave the healthcare centre and return to D wing when he
was fit, as he felt that he could not function properly due to problems with other
prisoners. These problems may have been related to information that the man
had given to staff.
48. The nurse saw the man again on 9 August. She wrote in his medical record
that, while he remained agitated, distressed and had chronic low self-esteem,
he was beginning to understand the reasons for his feelings. She added that
he had started to open up to his deep rooted issues, although he was still
guarded about revealing his full history.
49. At 10.30am on 11 August, the man was present for the first ACCT case review.
The Healthcare Officer wrote that the man was more settled but needed to
control his temper when discussing his moods. It was decided to keep the
observation levels the same as when the ACCT was opened (that is, once
every two hours).
50. At 9.00am on 14 August, a sixth officer made a long entry in the man’s ACCT
document. He wrote that the man was very tearful, and had asked for a move
to D wing once his time in healthcare was over as he had problems that
followed him around the prison. The man also said that he found it very hard
coming to terms with his mother’s death. The sixth officer spoke with the
chaplaincy regarding some counselling. The officer recorded that he was told
by the chaplaincy that they were not taking any new referrals at that time.
51. The man saw the consultant psychiatrist again as a routine follow-up on 14
August. The man was very distressed about the visions he was having of his
mother. During the interview with my investigators, the consultant psychiatrist
described how the man presented:
“I found him very anxious, agitated, seeing visions and hearing voices,
‘always my mother’ he said ’felt like my mother was crawling all over me’,
which as I said was quite striking and unusual for a bereavement reaction.
Found it very distressing, even saw her on the television, he said ‘I thought
12
I was going to explode’ and at that point he said ‘that’s why I smashed up
the room’, because that was after he smashed up the cell. ‘I’ve never
been like this before’ he said, ’I was hoping I was going to get better but
actually I’m feeling worse. Some staff seem to disbelieve me, other staff
are helpful.’ He said he wasn’t sleeping, the zopiclone only helped him for
a short while, he was waking constantly, though better last night he said,
‘crying my eyes out this morning, can’t concentrate. Tried to cut myself
last night’, so obviously there was that first episode of self harm then on
the 14th. ‘My mother seems so real, like you sitting opposite me.’ So my
impression was a severe bereavement reaction, quite severe, agitated but
not psychotic in the narrow sense and medication, I decided to stop the
olanzapine which is an anti-psychotic, it wasn’t helping him, it wasn’t me, it
was somebody else who prescribed that, put him on some promazine
which is a phenothiazine drug but is more a sedative drug, it hasn’t a very
strong anti-psychotic property but it would really help him with sedation
because he was very agitated and roused and I thought it would be helpful
to calm him a bit, but also to continue the lorazepam which is another
sedative drug and the citalopram the anti-depressant and the zopiclone.”
52. At 3.40am on 17 August, the man was very anxious and sat on his bed with two
figurines on a plate next to him. When a seventh officer asked who they were,
the man replied that they were his parents and that they wanted a sacrifice. At
4.00am, the man was still awake but said that he was okay. At 4.30am, the
man was still agitated. He told the officer that he was continuing to hear voices
and his mother was telling him to be prepared. The officer then saw that he
had made a small cut to his right arm.
53. At 10.30am, a second nurse wrote in the medical record:
“At around 10.00am the man became very agitated in his cell. He was
pacing up and down with clenched fists saying that the voices would not
go away, the man was crying throughout. He went on to explain that the
voices were telling him to harm others which he did not want to do, so
therefore he felt he would have to harm himself. The man then walked to
the gated cell with nursing staff ...”
54. When the man was moved to the gated cell he handed a sharpened plastic
knife to staff. His CSRA was increased to high risk until approval for sharing
was given by medical staff. The man’s ACCT observation levels were
increased to every hour.
55. An hour later the man was seen by the prison doctor. The doctor wrote that the
man was a lot calmer but was still agitated and holding his head whilst pacing
the cell. The man told the doctor that he had been up all night as he had
visions of his parents being in the cell with him. The prison doctor prescribed
an additional 50mg of chlorpromazine for his agitation to be administered at the
discretion of the nursing staff.
56. The rest of the day passed without incident, but at 3.40am the next morning (18
August 2007) it was noted in the ACCT that the man was awake and saying he
was hearing voices.
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57. Whilst out of his cell for exercise at 11.30am, the man approached a second
senior officer and told him that he recognised another prisoner who had
assaulted him about 18 months previously over a dispute about an ex-girlfriend.
The second senior officer submitted a Security Information Report (SIR). It was
decided staff should be informed about the situation and the two men should be
kept apart.
58. The man was given 50mg of chlorpromazine during the morning of 19 August
as he was agitated.
59. On 20 August, the prison doctor saw the man in healthcare. He wrote that the
man was still agitated and was repeatedly folding his clothes. The man told the
doctor he was worried he would lose control and harm someone. The nurse
had requested that diazepam be substituted for chlorpromazine as the dose
can be more easily tolerated. The prison doctor agreed and stopped the
prescription for chlorpromazine and lorazepam. He started the man on 10mg of
both diazepam and olanzapine. He also wrote that he would consider a mood
stabiliser later.
60. Two days later the man attended another ACCT case review. It was recorded
that his level of suicidal and self-harm tendencies had greatly reduced. The
man said that he was very apologetic for his recent actions. The review panel
decided to change the observation level to once every two hours.
61. The next few days passed without incident. On 28 August, the prison doctor
wrote that the man was worried that he would become addicted to diazepam.
The doctor reassured him but reduced the morning dose to 5mg. The man said
he was thinking of returning to a wing but wanted a single cell. During the
afternoon there was another ACCT review. The panel decided that the
observation level could be reduced to three times during the day and night.
62. On 30 August, the prison doctor wrote that the man was happy with the
reduction of diazepam but he would like to continue with the zopiclone for a few
days.
63. The next day, a second consultant forensic psychiatrist, talked with the man at
the request of his solicitors. The psychiatrist concluded that the care the man
had been receiving over the previous few weeks had begun to improve his
mental state.
64. The mental health nurse wrote in the medical record that the man should
remain in healthcare until he was reviewed by the consultant psychiatrist.
However, on 3 September the man spoke with the nurse about returning to G
wing because he did not feel that there was enough activity in healthcare. The
man moved back to G wing the next day.
65. At 11.05am on 5 September during a period of unlock, an eighth officer
responded to a cell bell at the man’s cell. He saw the man holding a bloody
tissue to the right side of his face. The man told the officer he had been cut.
The officer saw that the man had a one inch vertical cut above his right eye and
another about one and a half inches long below the same eye. The man said
14
he had been in a friend’s cell on the ‘ones’ landing drinking tea when another
prisoner came in and, after a brief argument, cut his face. The man refused to
name the prisoner responsible but said that it was because of what had
happened earlier in the year (when he had been asked to bring drugs in). The
man was returned to healthcare and it was decided that he would remain there
until space became available on D wing.
66. Also that day, a governor decided not to proceed with any disciplinary charges
relating to the man smashing a television and biting an officer on 6 August.
The man appeared to be in good spirits with no thoughts of self-harm over the
next few days. The prison doctor wrote in the medical record that the cuts to
his face were healing well and the man was asking for sleeping pills, although
there was no evidence of insomnia.
67. The man moved to D wing during the afternoon of 10 September. He went to
court the following day and was remanded again until 18 September.
68. An ACCT case review was held on 12 September when it was decided to close
the document as the man said he had no more thoughts or intention of suicide
or self-harm. He said he got on well with his cellmate and he would ask for
help if he felt himself ‘going down hill’. The post closure interview with the man
was set for 19 September.
69. A ninth officer made an entry in the man’s wing history sheet on 16 September
saying that he had settled into the wing routine very well. The officer added
that the man was a very quiet person who did not leave his cell when the door
was left open because his cellmate was a cleaner.
70. The ninth officer was the man’s personal officer at the time. (At Bristol a small
number of cells are allocated to each wing officer. Those officers then
introduce themselves to the prisoners in the cells as their personal officer. That
officer is then the prisoner's first port of call if they have questions, complaints
or need advice. If a prisoner moves out of a particular cell he may have
another personal officer allocated to him.)
71. On 18 September, the man was further remanded until 28 September. During
a cell search later that day a mobile telephone charger was found hidden
behind the picture board in the man’s cell. Both the man and his cellmate were
put on disciplinary report. The next day the man pleaded guilty to the charge.
He wrote a confession saying that he had found the charger in the bin and had
stupidly kept it, intending to use the wire to get a better reception on his radio.
A second governor found the charge proved and decided that the man should
lose 80 per cent of his earnings and his canteen privileges for 21 days as
punishment. (Canteen is the name given to purchases via the prison shop
such as sweets, tobacco and personal articles.) The ACCT post closure
interview with the man, scheduled for 19 September, did not take place as
planned.
72. On 28 September, the man was further committed to Bristol Crown Court and
remanded until 10 December.
15
73. On 30 September, a Reverend who is a member of the prison chaplaincy team,
went to see the man. He told the man that the prison had received a call from
his sister to say that his father had died. The man took the news badly, saying
he could not continue with life and that he would rather be dead. The man was
offered and made a telephone call to his sister. He was later put into a safer
cell as a precaution, and the Reverend asked staff to open an ACCT as he
thought that the man was suicidal. (A safer cell is a cell where places to attach
a ligature have been designed out as far as possible.)
74. A tenth officer opened the ACCT document. The man said he did not want to
go back to healthcare as he would prefer to stay with his cellmate. This was
agreed by a third governor. The man was informed that he could use the
Samaritans phone or the Listener system. (A Listener is a prisoner who
volunteers to be trained by the Samaritans to carry out a similar role within the
prison.) It was also decided to set the ACCT observation levels at every 15
minutes with frequent conversations through each shift.
75. An eleventh officer wrote the following entry in the ACCT document at 3.30pm:
“The man appears to be in shock at present and has very mixed feelings
about the news of the death of his father. Following his mother’s death in
March, the man became very unstable and feels he will go down the route
again. Suggested he requests a visit from his sister as that may help him
deal with the news. Assessment delayed until tomorrow, when hopefully
the man will be able to articulate further how he is feeling emotionally.”
76. The third officer conducted the assessment interview on 1 October. The man
said he was suffering from shock at the news of his father’s death but wished to
be treated normally and to lead a normal prison life. When asked about any
previous acts of self-harm, the man said he had cut his wrists whilst in
healthcare some seven months previously on hearing of his mother’s death.
(The man did not mention the overdose attempt he had spoken about to the
senior officer.) Later that day, a third senior officer and the third officer
conducted an ACCT case review when the following was recorded:
“The man is obviously deeply shocked by the whole scenario. He
appreciates that staff are here to help and assures us that he will seek
help if required. Sleep is his only release at the moment and therefore 3x
day & night observations are appropriate. He will be seeking to go to the
funeral in due course.”
77. The rest of the day passed without incident. The man appeared to be coping
as well as could be expected. There is an entry in the ACCT document by the
third officer at 8.00pm saying that the man had been quiet all evening, watching
television and chatting to his cellmate.
78. The next morning, the tenth officer wrote the following entry in the ACCT
document:
“Had a lengthy chat with the man. He feels a lot of pent up tension and
does not want to feel this way. Is having difficulty explaining himself and
16
exploring his feelings after his loss. Have explained about a single cell
and other options open to him.”
79. Later that morning, the man spoke to the chaplain who described him as tense
and concerned about when his father’s funeral was to be. The man went to his
work as an industrial cleaner in the afternoon but became upset and tearful.
The twelfth officer told the man’s personal officer, who spoke with the man
when he returned to the wing 15 minutes later. She wrote the following entry in
the ACCT:
“The man is very upset today, stated it is all too much, being in prison and
having to rely on others for information. He does not know when the
funeral will be, or if he can attend. This is getting him down. I have told
him to put applications in tomorrow for emergency pin credit to be put on
and his sister’s new number. At least he will be able to chat with her
himself. Also I have told him to put in an app [application] to see the
chaplain again. He thanked me for talking to him.”
80. The man spent a quiet night and did make the applications the following
morning (3 October 2007). The chaplain went to see the man that afternoon
and told him the details of the funeral. At 5.15pm, the third officer wrote that
the man had had a reasonable afternoon and was feeling a lot easier now that
he knew the date of the funeral. She added that when he collected his tea
meal he seemed fine.
81. On 4 October, the man attended a stress management group and appeared to
enjoy it. The next day it was noted in the ACCT that the man appeared to be in
good spirits throughout the day.
82. When the man collected his medication from the treatment hatch on 6 October,
staff observed that he did not swallow the diazepam (valium) tablet but tried to
walk off with it. When challenged, he dropped the tablet to the floor and
showed his empty hands. The staff warned him that he would be put on
disciplinary report if he did it again. The man spoke to his personal officer
afterwards and gave her the impression that it had not been the first time he
had ‘palmed’ his diazepam. The man explained that he needed them more at
night.
83. The man apologised to the staff at the treatment hatch that afternoon and
assured them he would take his medication correctly. However, staff saw him
take the tablets from his mouth and conceal them in his night in-possession
medication bag. The man told staff he had been doing it for some time. He
said that it was not to sell his medication but to take it at night when he needed
it more. The man was put on an IEP warning and told he would be given his
medication in the evening to help him sleep.
84. At 7.00pm, staff saw that the man had cut both of his wrists with a piece of
glass. The man told the nurse who treated his injuries that he had cut himself
as the result of feeling very low due to the death of his father. There was one
cut to his right wrist which required pressure to be applied for four minutes to
stem the blood flow. There were two cuts to his left wrist which were not
17
bleeding when the nurse attended. The nurse wrote that the man had full
sensation, colour and movement to his fingers and thumbs. The man was
placed in the gated safety cell in healthcare overnight with his radio. He told
staff he would like to speak to the mental health team as he felt he was ready to
talk about his parents’ deaths.
85. At 8.00am the next morning (7 October), a thirteenth officer wrote in the ACCT
that the man was up and about saying he felt stupid about what had happened
the night before. The personal officer spoke with the man later that morning.
She wrote that the man said he did not mean to mess staff about or flare up at
them. He said he felt he was ‘losing it’ as he had done before. The man told
the officer he really wanted to return to his cell. She replied he could do so
once he had seen the doctor.
86. The man was seen by the doctor later that morning and returned to his double
cell. At 2.10pm the man attended an ACCT case review. The third senior
officer wrote that the man was obviously very distressed about the death of his
father, and wanted to get the funeral over with so that he could move on. The
man said he could not explain why he had cut himself the previous evening, but
claimed not to be suicidal. The man and the staff discussed the need for trust
on both sides.
87. At 5.00pm, the fifth spoke with the man. The officer then contacted the mental
health team and explained that the man had not yet been seen. He was told
that the mental health nurse was on leave but they would arrange for someone
to see the man before his father’s funeral.
88. At lunchtime on 8 October, the man spoke to the third officer about moving into
a single cell so that he could ‘get his head together’. He assured the officer he
would not self-harm. The man’s personal officer had a similar conversation
with the man at 5.20pm. The man assured her that he desperately needed
some time to himself and would not do anything to jeopardise that. The
following morning, the man thanked the man’s personal officer for letting him
move into a single cell.
89. The consultant psychiatrist saw the man again on 9 October. He remarked on
the fact that the man had gained weight since he had last seen him, but agreed
with one of my investigators that it could have been a side effect of the
chlorpromazine he was taking. He said the man was still receptive and keen
for help. In interview, the consultant psychiatrist read from the notes of his last
consultation with the man:
“’I don’t understand why it’s all happening, to lose my step-father, mother,
father all in two years. I cut my wrists seriously and my cell mate saved
my life’ he said. ‘No point in going on living, the little hope that I had is
now gone, it’s been dashed.’”
90. Later in his interview, the consultant psychiatrist spoke about whether, in his
opinion, the man’s intention was to end his life:
18
“I have little doubt from what I know of how his death occurred, that this
was a deliberate and it’s picking up the negative bits. I mean people in
this situation as we all are, are ambivalent, part of them wants to live, part
of them wants to die you know, there’s a weighing up and for him. What
was striking in his mental state was fluctuating as well and there was both
parts of him as it were, if you like, in battle, the part that wanted to live, that
had hope you know, but his hope after his father’s death was clearly
dashed, and although he was talking about due in court 10 December, I
mean that’s not a statement of somebody who has decided at that point to
kill himself. I’m quite sure when I interviewed him, he had no intention of
killing himself, but with the background of impulsiveness, and I don’t know
what happened in detail between when I saw him and his death but, of
course we know the funeral happened in between but, and the sense of
being bereft in this world and all this happened to him. But the tragedy is,
people like this often, the mental state fluctuates and part wants to live and
part, at times wants to die, and of course if they act on the point, at their
lowest, that can result in their death, notwithstanding there were parts of
them that. It’s quite different from someone who has got a severe
enduring depressive illness with suicidal ideation, that’s a different thing,
that clearly, you can treat that depression, but someone like this, a
grieving reaction against a background of vulnerable personality, it’s going
to fluctuate a lot.”
91. As a result of his consultation with the man, the consultant psychiatrist
prescribed a 5mg increase of diazepam and reintroduced 100mg of
chlorpromazine.
92. The ninth officer wrote in the ACCT document at 11.55am on 10 October: “in
work all morning. Did not raise any concerns.” It was recorded later by The
tenth officer that The man was out on association that evening.
93. The next day the ninth officer made three entries in the ACCT document. At
8.45am she wrote that the man spoke to her saying he was alright, laughing
and joking with her. At 11.50am she gave him a verbal warning for having a
towel up at his cell window for the second time. Finally, at 5.05pm, the ninth
officer wrote about a long chat with the man. He told her that he had been to
stress management and explained how he was intending to use the relaxation
techniques. The officer reminded the man about the relaxation CDs available
and the man said he would ask if he wanted one. I note the man’s attendance
at the stress management session is not mentioned either in the ACCT or in his
medical record.
94. At 7.30pm, the third senior officer and the man’s personal officer conducted
another ACCT case review with the man. The third senior officer summarised
the review as follows:
“The man is looking for closure after the funeral tomorrow, and then
moving on with life. Being in a single cell seems to have helped him
through this and we will review this on Monday. He assures us that he will
tell staff how he is feeling when he returns from the funeral tomorrow.”
19
95. The officers decided that the next ACCT case review should be held the
following Monday when they were both back on duty. It was decided that the
frequency of the observations on the man would remain at three times during
the day and three times during the night.
96. On 12 October, the ninth officer wrote in the ACCT document that the man had
been awake since 3.30am and was extremely worried. He said his stomach
was turning over but he was trying to use his stress management techniques.
The officer advised him to go to work even if he did not feel like it as he would
be with his friends. At 10.10am the ninth officer made another entry stating that
the man had gone on exercise instead of work - which staff felt was good as it
got him out of his cell.
97. The man’s sister asked my investigators if the man had been sedated to attend
the funeral. He had not, but he was taking a number of drugs and just two days
previously the consultant psychiatrist had re-introduced chlorpromazine which
can have a sedating effect.
98. At 1.00pm on 12 October, when the man returned from his father’s funeral, he
told staff it had gone well. He said he was proud of himself for getting up and
speaking briefly about his father. He also said he was looking forward to his
next stress counselling session when he could talk about the funeral then.
99. The man attended stress management that afternoon. The sessions were run
by a trainee psychologist. After the session the trainee psychologist wrote in
the ACCT document:
“Spoke to the man for over an hour regarding his anxiety and stress
management issues. He presented as less anxious, as normal and
reported to be feeling numb following the funeral. He finds the PMR
relaxation technique useful and said he used it before the funeral today. I
have encouraged him to use this over the weekend and I will see him next
week. He is talking about his future and has requested info on therapeutic
communities. To follow up next week.”
100. It is interesting to read in the trainee psychologist’s interview with my
investigators that the man described the occasion when he cut his wrists as a
suicide attempt. That echoes what the consultant psychiatrist recorded during
his last session three days before: “Cut my wrists seriously – my cellmate
saved my life”. Both are in contrast to his statement to staff at the case review,
the day after he cut his wrists, when he said he could not explain the reason for
self-harming but claimed that he was not suicidal.
101. At 5.20pm, the ninth officer made a further ACCT entry which said that she had
spoken at length to the man. He thought his talk with the trainee psychologist
had helped him a lot and felt very positive at that time. The ninth officer told the
man that if he wanted to talk he could speak to her or a Listener, and have
access to any of the stress management CDs or books.
20
102. I am pleased to see written evidence of the increased concern by staff in the
ACCT document at 8.30pm. The night patrol officer recorded that there were
“concerns given due to the man going to his dad’s funeral”.
103. It was recorded that the man slept through the night of 12/13 October. At 12.00
midnight an ACCT entry states: “quiet as normal, but stated he is feeling ok”.
The tenth officer recorded that the man was watching television in his cell after
collecting his tea and there were no apparent problems. The man passed
another quiet night.
14 October 2007
104. On 14 October, a fourteenth officer wrote the last two entries in the ACCT
document:
“09.20 the man unlocked for kit change & shower, very quiet, spoke to
other prisoners and collected medication. No issues at present.
“11.15 Unlocked for lunch, no issues, just quiet at present, declined
exercise.”
105. At about 3.36pm, the fourteenth officer was unlocking the cells on the two’s
landing on D wing. He looked through the observation hatch window of cell 2-
14, the man’s cell. He looked down and saw the man’s back. At first he thought
the man might be bending down to get to his locker. He started to open the
door carefully and then realised that the man was lying on the floor. The officer
called for assistance and the fifteenth officer, who was nearby, responded.
They got into the cell and turned the man onto his back at which point they saw
a ligature of torn bed sheet around his neck.
106. The fifteenth officer shouted out of the door that there was a ‘code blue’ and
then cut the ligature free, using the safety knife issued for that purpose. (A
code blue call alerts other staff to an emergency medical situation involving a
severe breathing problem.) The officers also noticed that both of the man’s
wrists had strips of torn bed sheet wrapped around them, although there did not
appear to be any blood. The fifteenth officer thought that the man had attached
the bed sheet ligature to the cell ceiling light fitting and it had given way under
his weight.
107. The ninth officer and the second officer heard the call. The second officer
immediately relayed the message to the control room on his radio. The ninth
officer collected the emergency bag from the treatment room and alerted the
nurse. Meanwhile the initial two officers had commenced cardio pulmonary
resuscitation (CPR) on the man. The actions of the fifteenth officer at this time
showed professionalism and compassion. I particularly commend the speed
with which he began mouth to mouth resuscitation without the use of a
protective mask. I believe this was in the highest traditions of the Prison
Service, and the Governor will wish to consider if the fifteenth officer’ actions
should be formally recognised.
21
108. The ninth officer and other staff arrived at the cell and she set up the automatic
defibrillator. Over the next few minutes the machine went through its checking
cycle but did not at any time indicate that a shock should be administered.
(The machine works by correcting flawed rhythms in the heart, if detected, by
administering an electric shock.) Nursing staff arrived and took over CPR from
the officers. They in turn were relieved by the paramedics who arrived at
3.53pm having been called by the control room. Despite the efforts of the
paramedic team they pronounced the man dead at 4.07pm. The staff did not
find any letter of intent in the man’s cell.
109. One of the nursing staff, who went to the man’s cell, told my investigators that
in her opinion the man had been dead for some time. The ninth officer reported
that she could not get the plastic airway into the man’s throat as she could not
open his jaw, and the paramedics recorded that they were unable to insert an
airway due to rigor mortis. (Rigor mortis is a natural post death change in a
body causing stiffening of the muscles.)
110. The staff involved at the man’s cell were later brought together for a ‘hot’
debrief. The Governor was present. (The purpose of a ‘hot’ debrief is to
acknowledge what happened, acknowledge the role of the staff involved,
normalise the situation, and ensure that the immediate needs of the staff have
been met.)
111. The man had listed his grandfather as his next of kin. A fourth governor and
the eleventh officer went to his listed address to tell him of the death of his
grandson. They arrived at 7.10pm but were unable to pass the news. They
wrote in a decision log that the man’s grandfather was an elderly man who
would not answer the door. They reported back to the Governor who agreed
that enquiries would be made to determine other next of kin. Staff were aware
that the man’s sister had been in contact recently and efforts were made to find
an address. The following morning, the Reverend and the second governor
were unable to get an answer from the telephone number they had for the
man’s sister. They then went back to his grandfather’s address. Eventually,
the man’s grandfather answered the door and he contacted his grand-daughter,
the man’s sister, who arrived and was told the sad news.
112. The Reverend spoke with family members on several occasions after 15
October, and the second governor visited the family again on 29 October. The
prison contributed towards the cost of the man’s funeral.
22
ISSUES
113. When the man first arrived at Bristol he was seen by the reception nurse who
completed a First Reception Health Screen (FRHS). When asked about any
self-harm outside prison the man said that he had cut his face a long time
before. He did not mention that he had tried to commit suicide by using a drugs
overdose. However, the answer he gave should have triggered a referral to the
mental health team as required by a section in bold type after question ten on
the form. This was a very regrettable oversight, although in fact I do not believe
it made any material difference to the quality of care the man received.
114. The reception nurse had been working at Bristol for ten years and was
responsible for training other nurses to complete the FRHS. During her
interview for this investigation, she admitted she had not made the referral and
could not give an explanation for the omission. I am aware that in a more
recent death at Bristol the reception nurse also omitted to make the necessary
referral after a positive answer to question ten on the FRHS.
115. My investigators in this case immediately brought the matter to the attention of
their liaison officer who assured them it would be dealt with as a training issue.
(The reception nurse is no longer employed at Bristol.)
The Governor, together with the Healthcare Manager, should commission
a sample audit of recent First Reception Health Screen forms and ensure
that any necessary remedial staff training is swiftly completed.
116. On 23 June, the prison doctor went to B wing as he intended to see the man
regarding his substance use and to start a detoxification regime. At the time of
the doctor’s visit the man was not in his cell. As a result the man was not seen
until the following day. There is no evidence that starting his detoxification
regime a day later had any detrimental effect on the man’s physical or mental
health. However, in a number of deaths that I have investigated the delay in
starting a detoxification regime was significant.
The Governor should ensure that prisoners are made available for
medical consultations whenever possible.
117. The man saw the consultant psychiatrist on 14 August 2007, and during the
consultation told him he had tried to cut himself during the night. Although that
information was written up in the consultant psychiatrist’s notes in the medical
record, the self-harm information was not written in the ACCT document. In
fact, there is no mention of the consultation itself in the ACCT. There is also no
evidence that knowledge of the man’s attempted self-harm was passed to any
of the discipline staff or other medical staff.
The Governor should ensure that all persons having contact with
prisoners on ACCT documents are aware of the requirements and
responsibilities for entries in that document.
23
118. The above information would probably be treated as information given in
confidence. As I have discovered in many of my investigations, medical
confidentiality is usually the reason cited by healthcare staff for not sharing
information given with discipline staff. Prison staff and visiting doctors (not only
at Bristol) appear to believe that they are not allowed to share medical
information.
119. Whilst I am conscious of the importance of medical confidentiality, I think that,
when the need arises, prisoners might sensibly be asked to sign a consent form
allowing information to be shared with senior wing staff. Having a clear policy
for disclosure will help prison healthcare staff to recognise that in certain
circumstances such disclosure is both lawful and beneficial. Prison Service
Instruction (PSI) 25/2002, ‘The Protection and Use of Confidential Health
Information in Prisons and Inter-agency Sharing,’ which is still in force, laid
much of the groundwork for such a policy. However, in the six years since its
introduction I wonder if the views and actions of prison healthcare professionals
have changed sufficiently.
120. I am pleased to see that the latest version of Prison Service Order (PSO) 2700,
published on 26 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].”
121. Annex 8V of the PSO adds:
“Information-sharing between healthcare and other staff
Safer Custody Team Leaders, Health Care Managers and Mental Health
Managers should be working together to ensure that information is
appropriately shared between healthcare and residential and other prison
staff … sharing risk and basic care information with discipline staff who
manage a prisoner is not breaking medical confidentiality [emphasis in
original].”
122. In May 2008, the Director of Offender Health, Department of Health, wrote a
letter to PCT Prison Health Leads, Prison Governing Governors, and others.
He wrote about ten best practice issues arising from detailed analysis of 120 of
my reports. Number 8 in the list was as follows:
“Promoting an integrated approach to the care of people in prisons
24
The reports have demonstrated that some differences in the aims and
cultures of NHS and Prison Service at local level 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.”
The Governor, together with Bristol PCT, should draw up and publicise
widely a procedure for the obtaining of consent and the subsequent
disclosure of prisoners’ confidential medical information in appropriate
circumstances 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.
123. In many of my investigations I have noted that the personnel involved in ACCT
case reviews are often those staff who happen to be available, rather than
those who have the greatest knowledge of the prisoner concerned. In this
case, the ninth officer, who was the man’s personal officer for a while, said she
is very rarely asked to take part in a case review for one of her prisoners or
even approached for an opinion. When the nurse from the mental health team
was asked by my investigator if she had been invited to the case reviews, she
replied:
“No, I hadn’t been invited. Unfortunately, being in the healthcare centre and
not on the wings all the time, we don’t know when the reviews are due;
unless we are invited we don’t know when they are happening.”
124. I believe that every effort should be made to include staff with knowledge of the
prisoner and those able to make meaningful contributions on case review
panels.
125. Annex 8G (sections 14 and 17) of PSO 2700 states:
“14 - The first case review must be attended by the Unit Manager and the
Case Manager (where different from the Unit Manager). Wherever possible,
it should be attended by the Assessor. When considering who to invite to
the case review, the Unit or Case Manager ought not to be restricted by
thinking only of staff who have met the prisoner; they should try to think of
who else could positively contribute. It should also be attended by a
member of staff who knows the prisoner well (such as personal officer or the
officer who raised the initial concern). Where it is clear that there are mental
health or drug/alcohol issues, an appropriate member of healthcare staff
must be invited to make a contribution to the first review, in writing or by
telephone if they are unable to attend at such short notice. The appropriate
member of the Chaplaincy Team must also be invited to attend. Each case
must be treated individually and attended by staff involved in the care of the
prisoner, and where a provider of any specialist service (e.g. healthcare,
mental health services, substance misuse, Probation, psychology, family
advice, bereavement counselling) is referred to or otherwise involved in the
care of a prisoner on an ACCT Plan, that specialist must be invited to
contribute to the ACCT case reviews of that prisoner.
25
“17 - The second and subsequent case reviews usually take place under less
pressure of time than the first one. Therefore it is possible that a wider range
of staff and specialists (see 14 above) may be able to attend. One of the
attendees must be the named Case Manager (and failing that, the Manager
responsible for the prisoner’s location), one a residential officer who works in
the area where the prisoner is located and the other an appropriate member of
non-discipline staff …”
The Governor and the Safer Custody Manager should ensure compliance
with PSO 2700 Annex 8G sections 14 and 17.
126. On 5 August 2007, during the ACCT assessment interview, the man told the
senior officer that he had tried to commit suicide in May by overdosing on
heroin and valium as he wanted to be with his mother who had died a few
months before. He added that he was not happy to have been revived. That
information was not known by the officers who were making decisions about
the man’s risk level after the death of his father as he had given different
information to the third officer on 1 October. During her interview, the man’s
personal officer said that she really did not know whether possession of that
information would have changed her attitude towards the man’s risk of self-
harm.
The Prison Service should consider amending PSO 2700 to require ACCT
assessors to review recently closed ACCT documents relating to the
same prisoner when a new ACCT document is opened.
127. After the man’s ACCT document was closed on 12 September, a post closure
interview was scheduled to take place a week later on 19 September. The man
was present at a disciplinary adjudication at that time, and there is no evidence
that the post closure interview took place either that day or any other. At least
one post closure interview is required as part of the ACCT plan.
The Governor and the Safer Custody Manager should ensure that ACCT
case managers are aware of their responsibilities regarding post closure
interviews.
128. On 11 October, the day before the man’s father’s funeral, an ACCT case review
was conducted. At that time the levels of observations were set at three times
during the day and three times during the night. The two officers who
conducted the review decided to schedule the next case review for 15 October,
three days after the funeral.
129. I am aware that Prison Service Order 2700 says in annex 8:
“Wherever possible the Case Manager should arrange subsequent
reviews at a time that he or she can be present, in order to provide some
continuity of care for the prisoner. Where the named Case Manager
cannot attend, they must explain to the prisoner who is to take their place
at the review, and record that they have done this.”
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130. The man’s personal officer explained in interview that both of the reviewing
officers were not back on duty until the following Monday (15 October), but
informal arrangements were made for staff to speak with the man on his return
from the funeral. On the inside front page of the ACCT document there is a
section entitled ‘Triggers/ warning signs to prompt immediate review and
person/ department to be called: to be considered as part of each Case
Review’. When the ACCT was opened on 30 September, the senior officer
wrote “Funeral and inquest of the death” in that section (referring to the future
inquest into the man’s father’s death).
131. Annex 8G – section 47 of PSO 2700 states:
“Where an ACCT trigger/warning signal is activated (i.e. event actually
occurs), or there are other concerns such as increases in frequency or
lethality of repetitive self-harm, changes in mood, and other factors or events
which may increase risk of suicide, the ACCT Plan must be referred to and
the planned course of action followed. The concern and the action taken
must be noted on the ACCT Plan, and the Case Manager must be informed
about the raised risk.”
The Prison Service should amend PSO 2700 to require an ACCT Case
Review if a trigger/ warning signal is activated or the prisoner experiences
a major life event.
132. In conclusion, it seems highly probable that the man decided to end his life
whilst grieving over the death of his father. About a month after his arrival at
HMP Bristol, the man had been identified with mental health problems. They
appeared to centre on his bereavement reaction to the death of his mother in
February 2007 and to that of his step-father in 2005.
133. The man also had a long history of drug abuse, and the effect of his
detoxification on his mood cannot be discounted.
134. I judge that the man received considerable input from the prison’s mental health
team, including assessments by a consultant psychiatrist. However, this report
has highlighted a lack of communication between those caring for the man, as
well as some shortfalls in the ACCT process.
Clinical Review
135. The clinical review was not available when the draft report was issued but it is
now annexed to this report. The clinical reviewer draws a number of
conclusions as set out below and makes three recommendations and highlights
two areas of good practice.
136. Conclusions:
1. The man suffered a serious episode of depression largely due to a severe
bereavement reaction
2. There was no evidence of psychotic disease
3. The depression had significantly resolved by the time of the man’s death
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4. The man hanged himself in an impetuous act of suicide
5. There were several factors identified within the clinical review that should
be addressed which are noted below. I do not believe that any of these
factors were relevant to the outcome
6. Resuscitation was carried out calmly and effectively.
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RECOMMENDATIONS
National
The Prison Service should consider amending PSO 2700 to require ACCT
assessors to review recently closed ACCT documents relating to the same
prisoner when a new ACCT document is opened.
Accepted - Assessors, in the ACCT training course, are encouraged to obtain as
much information as they can before they speak to an at-risk prisoner. The
assessment interview explores previous acts of self-harm/suicide attempts which
would provide additional information for the ensuring case review. There is currently
a review of ACCT on-going and this point will be considered as part of it. Target date
for completion (TDC) End September 2009.
The Prison Service should amend PSO 2700 to require an ACCT Case Review
if a trigger/ warning signal is activated or the prisoner experiences a major life
event.
Accepted (already in place) - PSO 2700, Annex 8G, currently states (at paragraph
47):- “Where an ACCT trigger/warning signal is activated (i.e. event actually occurs),
or there other concerns such as increases in frequency or lethality of repetitive self-
harm, changes in mood, and other factors or events which may increase risk of
suicide, the ACCT Plan must be referred to and the planned course of action
followed. The concern and the action taken must be noted on the ACCT Plan, and
the Case Manager must be informed about the raised risk “
Local
The Governor, together with the Healthcare Manager, should commission a
sample audit of recent First Reception Health Screen forms and ensure that
any necessary remedial staff training is swiftly completed.
Accepted - The Healthcare Manager is currently developing auditing systems with
particular reference to First Night Health Screening. TDC 1/3/09
The Governor should ensure that prisoners are made available for medical
consultations whenever possible.
Accepted - A review of prisoner availability and access to medical appointments has
been carried out to ensure prisoners are available for consultations where ever
possible. TDC 1/3/09
The Governor should ensure that all persons having contact with prisoners on
ACCT documents are aware of the requirements and responsibilities for
entries in that document.
Accepted - The Personal Officer policy has been fully reviewed and relaunched.
Management checks are now carried out weekly by residential win managers, and
monthly by Residential Governors. The Safer Custody Manager is currently
reviewing the ACCT case review process, to highlight the need for a full multi
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disciplinary approach. Compliance will be monitored via the Safer Custody
Continuous Improvement Plan. TDC 1/3/09
The Governor, together with Bristol PCT, should draw up and publicise widely
a procedure for the obtaining of consent and the subsequent disclosure of
prisoners’ confidential medical information in appropriate circumstances 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.
Accepted - Other establishments have been contacted for information and guidance
on what type of form they utilise to ensure this information is within Prison and
Healthcare provision. A new form will be introduced and a Notice to Staff issued
when the form has been devised. TDC 1/3/09
The Governor and the Safer Custody Manager should ensure compliance with
PSO 2700 Annex 8G sections 14 and 17.
Accepted - The Local strategy will incorporate this section. TDC 1/3/09
The Governor and the Safer Custody Manager should ensure that ACCT case
managers are aware of their responsibilities regarding post closure interviews.
Accepted - Post Closure reviews are now monitored by the Safer Custody team to
ensure they are completed within the required timeframes. Compliance will be
monitored via the Safer Custody Continuous Improvement Plan. TDC Complete and
ongoing.
Good Practice
The actions of the fifteenth officer showed professionalism and compassion. I
particularly commend the speed with which he began mouth to mouth
resuscitation without the use of a protective mask. I believe this was in the
highest traditions of the Prison Service, and the Governor will wish to consider
if the fifteenth officer’s actions should be formally recognised.
Accepted - The fifteenth officer has been nominated by the Safer Custody team
through the Employee of the Month scheme, the official performance recognition
scheme at HMP Bristol.
Clinical Review Recommendations
The processes triggering referral to the mental health team from the First
Health Screen should be clarified.
Processes of communication and documentation into the health record should
be reviewed
Documentation should always be legible
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Evidence of good practice
The resuscitation was carried out calmly and effectively by the combined team of
nurses and discipline staff and later with the paramedics.
The assessment, care and support of the man was to a high standard through the
health and mental health teams.
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