Individual at Cardiff

Investigation into the circumstances surrounding the
death of a man at HMP Cardiff in April 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2011
This is the report of an investigation into the circumstances of the death of a man in
April 2010 at HMP Cardiff. He was 36 years old when he died.
It is always tragic when a young man takes his own life and I would like to offer my
condolences to his family and all those touched by his death. One of my family
liaison officers has had contact with various family members during the investigation
and continues to assist them to contribute to this process.
I asked my senior investigator to conduct the investigation into the man’s death and
report on her findings. An investigator employed on a sessional basis by my office
assisted my investigator and wrote this report. Healthcare Inspectorate Wales was
asked to review the medical treatment he received whilst at HMP Cardiff. I am
grateful for this contribution to the investigation.
I want to take this opportunity to thank the Governor of the prison and his staff for
their assistance to my investigation. The Safer Custody Manager acted as liaison to
the investigators when they visited the prison and they appreciated his attention to
detail.
The man had been open with his cellmates, medical and other prison staff about
feeling low and how he faced a number of difficult problems. He was, however,
never explicit with any one person about how badly he was affected. No-one, staff
or other prisoners, believed that he would take his own life and everyone spoken to
during the investigation expressed shock at his death. As there was no specific
occasion when anyone assessed him as being at risk of suicide, I think that it was
reasonable not to put the suicide monitoring systems in place.
I do not make any recommendations of my own but I endorse three in the clinical
review. They concern blood pressure monitoring for detoxifying prisoners, record
keeping and giving prisoners advance notice of healthcare appointments. I do not
think that these matters had any material effect on his wellbeing or his decision to
end his life.
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.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman July 2011
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CONTENTS
Summary
The investigation process
HMP Cardiff
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was first remanded to HMP Cardiff on 9 December 2009. He had been
charged with offences following the death of a fellow hostel resident and it was
initially suspected that he might have supplied the drugs that had led to the fatal
overdose.
The Prisoner Escort Record Form (PER) that accompanied him from court flagged
up a history of depression as well as heroin use. However, at the standard health
screen interview on reception, he did not disclose any thoughts of suicide or self
harm and there were no immediate concerns about his presentation.
A heroin user for several years, he was immediately placed on the prison’s
detoxification programme for both alcohol and heroin. He completed the required
course of treatment and moved to an ordinary remand wing on 4 January 2010.
From early on in his time in prison, he talked about feeling “low in mood” and
described symptoms of flashbacks, palpitations and sleeplessness. He requested
an increase to the dose of Chlorpromazine, an anti-psychotic drug prescribed by his
own doctor in the community. He took it to alleviate the impact of Post Traumatic
Stress Disorder (PTSD) that he suffered as a consequence of childhood sexual
abuse. His request was granted and he was referred to the prison’s consultant
psychiatrist. He also asked for counselling, having had a positive experience of
abuse counselling during a previous sentence at HMP Parc. No such service was
then available at Cardiff, and he was advised to discuss other options with the
consultant psychiatrist.
When he first met with the psychiatrist on 2 February, he was again very open about
the extent of his problems. It was thought that, although distressing, his anxiety
symptoms were manageable and he was not at risk of harming himself. He hoped to
be transferred to Parc once he was sentenced where he could again receive
counselling which he felt best met his needs.
The psychiatrist did not assess him as mentally ill and agreed with the existing
diagnosis of PTSD. He shared with him the possible negative side-effects of long
term use of Chlorpromazine and suggested an anti-depressant instead. He agreed
to the change in his medication and was referred to a psychotherapist for emotional
support while he waited to be sentenced. In the event, he did not like the new
medication and stopped taking it after four days. The previous prescription for
Chlorpromazine was resumed.
He was eventually convicted of Intent to Supply and Possession of a Controlled
Drug, namely heroin, on 15 March. The fear that he would be charged directly with
the death at the hostel, which had created much early anxiety for him, had not
materialised. He was remanded again until 31 March for sentencing. In the event,
he was not sentenced on that day but instead attended the magistrates’ court in
relation to the earlier drug offences. He was due to be sentenced on 20 April but his
solicitor said that he did not think that he would have known this when he died. He
was anticipating a lengthy sentence.
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On 6 April, he again met the psychiatrist as part of a standard review. He
complained that the anti-depressant made him “worse” which was why he had
stopped taking it. The doctor confirmed that he could continue taking
Chlorpromazine and told him that he would pursue the appointment to see the
psychotherapist, which had not yet taken place. The doctor had no concerns about
him.
The next day, he moved to B Wing. He moved in with someone he knew and,
according to this cellmate, he was distressed the weekend before he died. He had
been on B Wing for less than a week when he took his own life. This was not long
enough for him to form supportive relationships with wing officers at a busy time on
that landing. Neither he nor his cellmate told staff about the emotional “turmoil” he
apparently experienced over the weekend before he died.
He was due to appear at the inquest into the death of the resident of the hostel on 16
April which had been postponed from 31 March. His solicitor had not been aware of
the impending inquest although he knew that the police wanted to speak to him in
relation to the matter. The investigation team could not find any evidence to confirm
whether he was aware that he was due to appear as a witness.
At about 9.15am on Monday 12 April, his cellmate went on a legal visit. That was
the last time he was seen alive. An officer made a fabric check (the daily security
check of the cell to ensure that there is no damage and need of repair) at 10.06am.
The officer would have seen him in the course of the check. Some time between
10.06am and 11.30am, when his cellmate returned to the cell and raised the alarm,
he tied a ligature made from a bed sheet around his neck and hanged himself from
the window frame.
The response to the discovery was competent and fast. Despite the likelihood that
he was already dead, officers tried very hard to resuscitate him. Their efforts and
those of the paramedics were unsuccessful and he was pronounced dead at
12.10pm.
My report contains three recommendations concerning healthcare arrangements.
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THE INVESTIGATION PROCESS
1. My colleague made a preliminary visit to HMP Cardiff on 15 April to open the
investigation. The investigation was then carried out by two investigators.
Notices were issued to staff and prisoners telling them about the investigation
and offering them the opportunity to speak with my investigators. No one
came forward as a result.
2. The investigators visited the prison on 12 and 13 May 2010 and interviewed
ten people: two prisoners who shared cells with the man, three prison officers,
two nurses, a CARAT worker (Counselling, Assessment, Referral, Advice and
Throughcare Services), a psychotherapist and a consultant psychiatrist. The
investigation team also visited the wings where he had lived.
3. The investigators met with the Governor at the start of the investigation at and
also at the end of their visit to discuss findings. No matters of urgent concern
were raised at this stage.
4. The investigator contacted the police officers investigating the offences with
which the man was charged, and his solicitor. She also spoke with the
probation officer who wrote the pre-sentence report for sentencing and was
sent a copy of this report for background information. In addition, she spoke
with the coroner’s officer with regard the inquest into the hostel resident at
which he was due to attend.
5. One of my family liaison officers telephoned the man’s mother on 7 May. She
followed up her initial telephone call in writing and included a leaflet with
information about the work of the Prisons and Probation Ombudsman. This
explained that the bereaved family could be involved in the investigation if
they wished.
6. Both investigators visited the man’s mother on Monday 19 July. The family
liaison officer has also spoken on the telephone with two of the man’s
maternal uncles. The following concerns and questions have been raised by
the family. I hope that the findings of my investigation answer these and any
other questions they may have and helps them better understand the events
leading to his untimely death:
(cid:127) The family questioned why the prison did not appropriately address his
mental health needs, despite him telling staff about them.
(cid:127) He had told his mother that the prison had stopped the medication he had
been prescribed by his doctor in the community to manage his mental
health problems and she wanted to know why.
(cid:127) His mother was aware of her son’s mental suffering at the time of his
death and she feels there was a possibility that he may have been hearing
voices. She wanted to know if any evidence was uncovered by the
investigation.
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(cid:127) His uncle asked if there were any concerns about his last cellmate and his
behaviour towards his nephew.
7. A copy of the draft report was sent to the Prison Service and their responses
to the recommendations are repeated verbatim in the recommendation
section.
8. The man’s family received a copy of the draft report as part of the consultation
period. Having considered the investigations findings, his family indicated to
my family liaison officer that they were unhappy with aspects of the report,
including what they felt were a number of inaccuracies and issues that had
been overlooked. Despite encouragement from my family liaison officer to
share their feedback, his family did not feel able to disclose their further
comments ahead of the report being made final.
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HMP CARDIFF
9. Cardiff is a local category B prison situated in the centre of the Welsh capital
and is the largest state-run prison in Wales. A category B prison is a closed
prison where do not need maximum security but where escape is made very
difficult.
10. General healthcare is provided by doctors and nurses employed by the Prison
Service. The 22 bed healthcare centre is two years old and offers 24 hour
nursing and medical cover. The local Health Trust also employs a consultant
psychiatrist for seven sessions a week to provide mental health clinical work
to the prison. A further session a week of mental health input is provided by a
local mental health facility, the Caswell Clinic. The mental health in-reach
team at Cardiff consists of five people, including the consultant psychiatrist.
Other team members are two community psychiatric nurses (CPNs), an
occupational therapist and an administrative worker. At the time of this
investigation, three members of the team were off sick, two of them long term.
The psychiatrist works across both primary and secondary care towards the
longer term aim of integrating the whole team. They provide services for
those with severe and enduring mental health needs as well as prisoners who
need counselling.
11. There is a detoxification wing where prisoners undergo a Lofexidine
detoxification. Wales does not use the Integrated Drug Treatment Service
(IDTS) now available in the prison estate in England. The aim of IDTS is to
provide a broader range of options for those with problematic drug use. For
those arriving at Cardiff without a community prescription of Methadone or
Subutex, the only option is to go through a 14 day detoxification. Once this
has been completed, and the prisoner is regarded as stable, they are moved
to ordinary location. The CARATs team provide longer term support for drug
users.
12. Like the rest of the prison estate in England and Wales, the prison is expected
to accommodate more prisoners than it was designed for. It has an
operational occupancy of 824 as of December 2009. This includes both
convicted and non-convicted men on remand and there is also a dedicated
wing for prisoners serving life sentences.
Her Majesty’s Chief Inspector of Prisons
13. The most recent Her Majesty’s Chief Inspector of Prisons (HMCIP) inspection
of the prison took place in January 2008. The inspection report noted
favourably:
“It suffers from all the difficulties of an overcrowded and pressurised prison
system. It is therefore to the considerable credit of the prison’s staff and
managers that it was nevertheless found to be performing reasonably well
across all of our four key tests: safety, respect, purposeful activity and
resettlement.”
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14. The inspection team felt that detoxification procedures were “sound” and that
“overall” there was a good level of healthcare. The report commented,
however, that:
“… it was disappointing that the enthusiasm of the safer custody manager
had not communicated itself to those staff responsible on a day- to- day
basis for supporting those at risk of self-harm. This required more
management attention.”
Independent Monitoring Board
15. Every prison has an Independent Monitoring Board (IMB) made up of local
people whose job it is to monitor standards to ensure prisoners are being
treated fairly and humanely. Each IMB is required to report every year on
their findings. The last IMB report on Cardiff concluded that it was “a well-run
establishment with good relationships between staff and prisoners”. It noted
that a general counsellor had resigned during that reporting year and no
replacement had been found.
Assessment, Care in Custody and Teamwork (ACCT)
16. Assessment, Care in Custody and Teamwork (ACCT) is a care planning tool
used by the Prison Service to help monitor and support prisoners identified as
being at risk of self harm or suicide. Any member of staff can open the ACCT
procedures by filling in certain documents detailing their concerns and the
process encourages staff to work together to tailor individual care to prisoners
in distress. Regular checks and reviews of the prisoner’s situation are built in
to the process with the ultimate aim of diffusing circumstances where suicide
or self harm can take place.
Previous investigations of deaths in custody
17. There were four apparently self inflicted deaths in 2009. None of these
people were subject to the enhanced monitoring of Assessment, Care in
Custody and Teamwork (ACCT) procedures at the time of their deaths. There
have been no other self inflicted deaths in 2010. The man’s death shares one
similarity with two of the deaths in 2009, in that it came as a shock to
everyone concerned.
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KEY FINDINGS
18. The man was arrested on 8 December 2009 after he had discovered the body
of a fellow resident at the YMCA in Cardiff. This man had apparently died
from a drug overdose and he was initially suspected of supplying the drugs
that killed him. He consistently denied this. He had also been arrested a few
days earlier on drug offences and released on bail.
19. He was remanded into custody at Magistrates’ Court on 9 December 2009.
He arrived at the prison and went through the usual reception procedures
including a standard health screen. Drug tests revealed the presence of
benzodiazepines (used to treat symptoms including anxiety and insomnia)
and morphine (opiate used for pain relief) in his system. He was interviewed
by nursing staff and allocated to the detoxification unit on C wing. He started
an opiate, benzodiazepine and alcohol detoxification. No immediate concerns
were raised about his risk of suicide or self harm although a history of
depression was identified in the Prisoner Escort Record (PER) that
accompanied him from court.
20. On 10 December, he underwent a standard assessment interview with the
CARAT worker on the detoxification wing. He had a visit from one of his legal
representatives on 14 December. This meeting was followed up by another
legal visit four days later.
21. He started work with members of the CARATs team on both 21 and 23
December. On 27 December, he is recorded in the medical record as
complaining of feeling “low in mood”. He had been prescribed
Chlorpromazine for post traumatic stress disorder (PTSD) in the community
which continued in prison. Chlorpromazine is an anti-psychotic drug which
has anxiety relieving and sedative properties. He explained that he had been
used to a higher dose than he was being prescribed at that time. He was told
that he would be referred to a mental health nurse the next day.
22. He was duly assessed by Nurse A on 28 December and discussed abuse he
had suffered as a child and flashbacks he was experiencing as a result. In
the medical notes it queries whether the level of dosage of his medication
should be reviewed. It was also recorded that he had no thoughts of self
harm and was advised to speak to staff if he had further concerns.
23. The next day he reported that he had suffered “palpitations” during the night.
There is evidence of a further assessment of his situation and the following
options were discussed:
(cid:127) He should see a community psychiatric nurse (CPN) to “get things off his
chest”.
(cid:127) He was advised that there was no counselling service at Cardiff, so he
should consider transferring to HMP Parc where he benefited from
counselling during a previous sentence.
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24. On 31 December, he was seen by a mental health nurse who increased the
dose of Chlorpromazine to 200mg daily to help with his “racing thoughts”.
After four days, however, he again saw a nurse to complain that his
medication was not working. He was advised by a nurse who saw him on this
occasion to persist with this dosage as it had not had long enough to be
effective. No other concerns were recorded. Staff noted that he was
participating in activity on the wing. He had good eye contact, which was
seen as a positive sign, and no thoughts of suicide or self harm.
25. The detoxification treatment was completed the next day and, on 4 January
2010, he moved to F Wing. He was placed in a shared cell and no immediate
concerns were recorded in the wing log.
26. He had an appointment with a Counselling, Assessment, Referral, Advice and
Throughcare Services (CARATS) worker, in early January 2010. Her role
was to help him to focus on his drug use now he was drug free after
detoxification. It is clear that he was motivated to make positive use of this
opportunity and he appeared committed to working with professionals to
achieve a drug free life. He talked about his need for abuse counselling and
his wish to transfer to HMP Parc as soon as he was sentenced.
27. She later said in interview with my investigators that she offered to refer him
to a member of the chaplaincy who was trained in bereavement counselling,
and will speak to prisoners more generally about their problems. However,
when she explained to him that there was a waiting list, he said he was “fine”
to wait for counselling to be arranged through the mental health team.
Following the CARATS session, he was given “homework” to do between
meetings. He showed his willingness to address his drug use by completing
the written exercises in an enthusiastic and thoughtful way.
28. His problems sleeping and his flashbacks continued and he sought help again
from medical staff via “sick parade” (prisoners request to see a doctor on the
day of illness) on 15 January. He mentioned that these problems stemmed
from previous abuse and coming off heroin. He was told to wait for his
psychiatric appointment and there is no record that he made any further
complaints before he saw a Consultant Psychiatrist on 2 February.
29. He seems to have been very open with the psychiatrist about the nature of his
problems. They had a lengthy discussion about appropriate medication and
the psychiatrist persuaded him to switch to Citalopram, an anti-depressant
used to treat major depression associated with mood disorders and PTSD in
particular. The psychiatrist’s medical advice was that taking Chlorpromazine
over time could lead to unpleasant and damaging physical side effects.
30. Although self confessedly “low in mood”, he did not strike the psychiatrist as
suicidal or at risk of self harm. The psychiatrist made a note to this effect in
the clinical record. Whilst acknowledging that there was no specific
counselling service at Cardiff, the psychiatrist decided to refer him to a
psychotherapist who attends the prison for one morning session a week. The
psychiatrist recognised that he had benefited previously from counselling and
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responded to this type of psychological support. The doctor sent a
comprehensive letter outlining his needs to the psychotherapist dated the next
day, 3 February. As a result of the consultation, Chlorpromazine was reduced
from 3 February and the new drug Citalopram issued from 4 February.
31. From the time of his arrival on F Wing, no problems were noted about his
behaviour. In the three entries from early January he was described as quiet
and spending a lot of time in his cell sleeping. On 4 February, however, he
was recorded as being “verbally aggressive” to nursing staff about his
medication.
32. He then refused to take Citalopram on 8 February and the psychiatrist agreed
to resume the prescription of Chlorpromazine of 100mgs twice a day on 9
February. He did not see him in connection with this decision but recalled that
he agreed to this change to help calm his “agitated state”. He had a visit from
his solicitor on 12 February. The next entry in the wing record on 14 February
comments on “further signs of non-compliance” after returning from getting his
medication. The entry goes on to say “a poor week from him”.
33. The disruptive behaviour appears to have been short lived, however, and the
rest of his time on F Wing seems to have passed much more peacefully.
Wing records throughout March say that he was calmer and there were no
concerns, although one entry described him as a “Jekyll and Hyde”. Two
police officers from two police stations both in Cardiff visited him on 8 March
in relation to the drug offences for which he had been bailed in early
December.
34. He was convicted of possession of a controlled drug with intent to supply and
possession of a controlled drug at Crown Court on 15 March. He was
remanded back to HMP Cardiff to await sentencing on 31 March.
35. He was due to be visited by a Detective from the police station on 19 March.
The police officer went to see him at the request of the coroner to obtain a
statement regarding the death of the YMCA resident. The Detective told my
investigator on the telephone that he had refused to see him.
36. On 22 March, he received a visit from his legal team. The next day, a
probation officer visited him in connection with the preparation of a pre-
sentence report for court. She did not deem him to be at risk of self-harm or
suicide, although he was open about the personal difficulties he was facing.
When he appeared at Crown Court on 31 March, sentencing did not take
place and instead he appeared at the Magistrates’ Court in relation to the
older drug charges. His solicitor said that he was fine on that day, although
preoccupied with wanting to know the length of sentence he might receive.
By this time, he knew he was not facing charges in relation to supplying drugs
to the hostel resident who died.
37. For his last few weeks on F wing, he shared a cell with Prisoner A. During
interview for this investigation, the prisoner said that he had known him
outside the prison but they had also had shared a cell for about five months at
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Parc in 2008 on a previous sentence. He felt he knew him well and spoke
warmly about him. Although he shared a lot about his problems with the
prisoner, his death came as a complete shock. He had never believed that
his friend was at risk of self harm and said that he would have alerted staff if
he had felt that he was in danger of taking his own life.
38. As a convicted prisoner, the man could no longer remain on F Wing. He left F
Wing on 1 April and was placed on A Wing until a place became available on
B Wing.
39. On 6 April, he was again seen by the psychiatrist for a routine follow up
review. He said he was “still the same really”. There had been no contact yet
from the psychotherapist and the psychiatrist recorded that he would follow
this up. He also said that Citalopram had made his anxiety and panic attacks
“worse”. They agreed that he would continue taking Chlorpromazine as much
for its sedative properties which helped him sleep.
40. The psychiatrist explained to the investigation team that he did not think that
Chlorpromazine was the right medication for his specific needs in the long
term. Nevertheless, he agreed to go along with his patient’s preference.
During his interview for this investigation, the psychiatrist was adamant that
he was not suicidal at this appointment.
41. On 7 April, he was allocated to cell 5 on B4, the top landing on B wing, to
share with Prisoner B. Again, the cellmates knew one another from their
acquaintance outside the prison and they had also been on F wing at the
same time. The prisoner says that they had not spent much time together on
the previous wing but he had noticed from a distance that he appeared “very
isolated” and “depressed”.
42. In his statement to the police and also in interview with my investigators, the
prisoner described him as very open about his emotional distress, once they
had started to share a cell. As well as talking about the abuse he had
suffered as a child, the prisoner said that his cell mate was also “in a turmoil”
about his sexuality. By his own account, the prisoner was sympathetic and
tolerant towards him when he shared his thoughts with him. He at no time,
however, thought he was suicidal or at risk of self harm and he too said he
would have told staff about any concerns. Although h did share with the
prisoner that he had been implicated in the death of someone who had
overdosed, he did not go into much detail or say that he would have to attend
an inquest. The prisoner commented that he had had a restless night on 10
April and did not sleep well generally.
43. The only one officer on B Wing who appears to have had any memorable
contact with him, who remembered him taking part in a sweepstake the officer
had organised for the Grand National on 10 April. He remembered him
coming to get his ticket. He also noticed that he shaved his head sometime
during Friday 9 and Saturday 10 April, although he did not think this was
unusual. This lack of contact with him is reflected in the recollections of two
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officers who, whilst knowing who he was, only recall him as a quiet person
who spent most of his time in his cell.
44. Prisoner B described him as being “very manic” on 11 April. They spent much
of the day talking through his issues. None of this appears to have been
conveyed to either discipline or medical staff. He remembered that he
received a letter from his mother with some money that day.
Events of 12 April
45. Prisoner B explained in his police statement that he awoke later than usual at
about 8.30am on Monday 12 April and the man was awake before him which
was also unusual. By the time he came to be interviewed by my investigators
on May 2010, his memory had dimmed but he could not remember having
any concerns about him that morning. He left the cell at about 9.15am to be
escorted to a legal visit. He did not return until after exercise had finished as
he went to see a friend on another landing after his visit and then went
straight to exercise from there.
46. Although Officer A initially remembered collecting him to go for exercise at
about 10.00am that day, he later acknowledged that he was confused with
another occasion. The officer has no memory of seeing him at all when he
asked prisoners if they wanted to go for exercise at about 10.00am that
morning.
47. The officer decided to combine unlocking the cells and making the
accommodation fabric check at the same time. This was not his usual
practice. In interview, he could not explain why he did so on this occasion.
The wing was described as very busy that day so he told the investigation
team that he might have wanted to speed things up by combining two tasks.
48. An accommodation fabric check involves staff physically checking cells for
damage and need of repair, in particular for security reasons. This must be
done once a day. Part of the overall check is a cell bell check when the bells
in each cell are pressed inside and then switched off by the officer on the wall
outside. The cell bell check for cell B-05 is recorded as taking place at
10.06am which is consistent with the officer’s original assertion that he started
to work his way round the landing to ask about exercise at the same time as
doing the accommodation checks at about 10.00am.
49. Although officers are not required to communicate with prisoners during
accommodation checks, the officer would have opened each cell door to and
reach inside to ring the bell. He said that he would definitely have seen him if
he had been hanging at that time, as he was eventually found directly in front
of the door. Although he could not specifically recall, he assumes that he was
in the cell but in bed at the time of the check.
50. There is no record or recollection by the wing officers of any other contact with
him or visit to his cell until his cell mate returned from exercise. Prisoner B
remembered eventually arriving back at the door outside the cell at about
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11.30am (although it could have been a few minutes earlier when other
timings are taken into account). He looked through the observation flap to
see him hanging from the window frame. He immediately shouted for help
and Officer B came running from the end of the landing where he had been
talking to another prisoner.
51. The officer unlocked the cell and immediately tried to support his weight. He
was helped by the prisoner who followed him inside. Officer C was next to
arrive and he cut the ligature around his neck with his anti-ligature knife. (This
knife is colloquially known as a “fish knife” or “fish hook” in the Prison Service
because it is shaped like a fish. Anti-ligature knives are issued to all prison
staff who are required to carry them at all times.) The ligature was made from
a green bed sheet.
52. The prisoner was asked to leave the cell by Officer D who had arrived at the
cell immediately behind Officer C. Officer A had also arrived from helping a
colleague on B3 landing with a collapsed prisoner. He helped Officer B and
Officer C to lay him on the floor to check for breathing. They could find no
sign of breathing and Officer B started cardiopulmonary resuscitation (CPR) at
a rate of 30 compressions to two breaths, without pausing to use his mask.
Officer C left the cell at this point.
53. Officer A took over compressions and Officer B continued mouth to mouth
resuscitation. A Senior Officer arrived and called the Code Blue emergency
call which signals to staff that someone has been found hanging. Various
incident logs time this as happening at 11.28am.
54. Nurse C responded to the Code Blue call and arrived to find his colleagues
giving CPR. He judged that they were doing a good job and he prepared the
defibrillator when it arrived. The defibrillator had been called for by the prison
doctor, who had also responded to the Code Blue. Officer A left the cell at
about this time because he thought there were enough people in the room.
55. Although Officer B said at the “hot debrief “ meeting that he thought Nurse C
had problems getting” the kit out”, this was refuted by the nurse when he was
interviewed by my investigators. When the defibrillator pads were placed on
the man no heart rhythm was detected and it instructed not to proceed with
CPR. However, CPR was continued as Mr B took over full CPR when Officer
A left the cell.
56. According to the Controller’s Death in Custody Check List the first call to the
Ambulance Service was made at 11.30am. A single crewed first responder
was on mobile patrol close to the prison and the paramedic logged that he
received a radio message at 11.36am and arrived at the prison a minute later
at 11.37am. This differs slightly from the check list which records that the
ambulance arrived at 11.33am. When the paramedic arrived at the cell he
found three people carrying out CPR and he took over CPR with the help of
prison staff until two other paramedics arrived at about 11.45am. Officer B
handed over to them and left the cell. The man was pronounced dead at
12.10pm.
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57. The clinical reviewer commented favourably on the “exhaustive attempts by
the emergency team” to revive the man. She concluded that the medical
response to the discovery of him was “quick” and that CPR was
“appropriately” undertaken.
Events after the man’s death
58. The Governor, chaplain and prison family liaison officer visited the man’s
mother at about 1.45pm that afternoon to break the news of his death.
59. It should be noted that this was the first day of the Governor’s appointment as
Governor of Cardiff. The fact that he responded so responsibly to the task of
breaking news of a death to a family in person when still so new in post is
impressive. Experience from other investigations conducted by my office tells
that families appreciate direct contact from Governors and we encourage this
wherever possible.
60. A full “hot debrief” meeting of the staff who responded to the emergency was
held that afternoon to establish what had happened and the sequence of
events. Staff who had direct contact with the man and who attempted to
resuscitate him were thanked and told where they could get support.
61. The family liaison officer continued to have contact with family members in the
weeks immediately after the death and visited to return the man’s belongings.
I understand that the prison complied fully with Prison Service guidance and
offered the family financial help with funeral expenses
16
ISSUES
Clinical care
62. A clinical review was prepared by the Healthcare Inspectorate Wales. In total,
five recommendations were made, three of which are endorsed in my report
(the third recommendation is repeated further in this section). One of these
concerns blood pressure monitoring as the man’s was not taken every day for
the first three days whilst undergoing detoxification which was not in line with
policy.
The frequency of blood pressure monitoring should be clearly stated
within the plan of care to ensure that prisoners are monitored correctly,
whilst undergoing detoxification.
63. The quality of the healthcare record keeping was variable and there were
many instances of the records being incomplete and/or inconsistent, and in a
number of cases both the information recorded, and the names of signatories
detailing the information was illegible.
The Head of Healthcare should ensure that all records containing
information relevant to prisoners’ health are maintained in accordance
with professional standards, e.g. as stated in the Nursing and Midwifery
Council Record Keeping: Guidance for Nurses and Midwives (2009).
64. The other two recommendations made by the clinical review are discussed
below and concern the man’s access to health professionals and obtaining
medical records from other prisons.
Assessment of the man’s risk of harm
65. A key question whenever someone apparently takes their own life is whether
there was any opportunity to intervene and prevent it. It was known that the
man had a history of alcohol and drug abuse and he underwent detoxification
on his arrival. He talked openly to medical staff and others about childhood
experiences of abuse which left him anxious and distressed. He had been
previously diagnosed with Post Traumatic Stress Disorder and had been
prescribed a drug, Chlorpromazine, by his own doctor in the community. In
prison, he described symptoms of depression, panic attacks, flashbacks and
palpitations to a range of health professionals and received medication to
address some of these.
66. On most occasions when he presented with these symptoms he was asked if
he felt suicidal or at risk of self harm. On no occasion did any professional
feel sufficiently worried to record immediate concerns or open the ACCT
procedures. He was not unusual in the general prison population as someone
who had been through damaging early experiences. In his case, this had led
to self medication through alcohol and heroin. He was struggling to some
extent after detoxification in prison as he was now faced with the re-
emergence of painful memories leading to flashbacks and interrupted nights.
17
67. The psychiatrist was aware of the difficulties facing him and assessed him as
needing treatment by agreeing to resume the prescription for Chlorpromazine.
His clinical opinion was that his condition was better served by different
medication but because he asked specifically for a drug he felt more
comfortable with, the doctor thought it was important to adhere to his request.
The problems that he had sleeping were a key factor as Chlorpromazine has
a sedative effect. The psychiatrist did not think that he was clinically
depressed and did not, therefore, refer him for further assessment or
treatment. He asked him on both occasions when they met whether he had
suicidal thoughts and was convinced by his replies that he was not thinking in
this way.
68. He also had significant contact with his CARATS worker. Again, she never
felt that he was at risk of taking his life. She has been trained to open the
ACCT procedures and has done so in the past when concerned about a
prisoner. He, although clearly troubled, did not cause her this level of
concern. She felt he was focused on the future and was able to manage his
anxiety.
69. Although it seems that he shared some of his personal and intimate worries
with a number of people in the prison, it does not seem that he shared
everything with any one person. His friend and cellmate knew about his early
abuse, that someone had died recently and that he was concerned about
being convicted. He did not seem to know about his dilemma about his
sexuality. Similarly, this was an aspect of his distress that he chose not to
share with the psychiatrist or his CARATS worker, the professionals he
confided in most. It seems that the only recipient of this last piece of
information was Prisoner B in the final week of his life.
70. He also shared some of his distress with people outside prison. He wrote
regularly to his mother and was candid about his frustrations about not getting
the in-depth counselling he felt he needed for his problems. Although she
worried about her son, his letters to his mother were quite varied in tone. In
some, he came over as quite upbeat and almost optimistic about his future
and at other times he appeared very down in mood. It was hard, therefore, for
her to form a clear picture of what was happening. His death was a terrible
shock for her as she had no indication that he intended to act in this way.
71. He discussed his symptoms of PTSD and anxiety with the probation officer
who interviewed him on 23 March for a pre-sentence report for court. He
disclosed, however, that he was receiving medication for anxiety and saw the
anticipated custodial sentence as an opportunity to get the therapy he
needed. Indeed, he thought he would have a better chance of receiving the
right intervention in prison rather than in the community where resources were
less accessible. She was clear in her assessment of risk of serious harm in
her report that:
“Probation records indicate that he has suffered depression in the past but
he disclosed no such feelings now. He discloses no history of self-harm or
18
suicide attempts. He is therefore not considered to pose a risk of harm to
himself.”
72. He was also visited by police officers and his solicitors on various occasions.
Again, none of these professionals passed on any concerns about him to
prison staff.
73. A number of professionals identified that he was suffering with depression and
struggling with the after effects of withdrawing from drugs. However, he was
not assessed as at risk of suicide which, without the benefit if hindsight, I am
satisfied was a reasonable assessment given his denial that he was thinking
about harming himself.
Opportunities to meet mental health staff
74. The psychiatrist did not refer him to the mental health in-reach team mainly
because he did not think he had a severe mental illness and that he would not
have benefited from such a referral. It is clear that there were plans for a new
integrated team of healthcare staff at Cardiff although these seem to have
stalled partly by the illness of key personnel. It is likely that he would probably
have been referred to the team if it had been in existence. In interview with
my investigators, the psychiatrist acknowledged the problems for mental
health interventions caused by long term staff sickness. How effective such a
referral would have been in preventing his death, however, cannot be known.
Even though the doctor referred him to a psychotherapist, he would have still
had to spend much of his time in his cell without access to appropriate
counselling.
Counselling at Cardiff
75. He had found counselling received in 2008 on a previous sentence and at
another prison (Parc) a great help and was actively seeking this route to
tackle his problems again. Unfortunately, there was no specific service of this
kind at Cardiff at this time. He appeared to have accepted this with good
grace and patience. The clinical review draws the conclusion that his medical
records should have been accessed from Parc. However, obtaining medical
notes from previous prison sentences is not routinely carried out across the
prison estate and therefore not a criticism which can fairly be lodged at
Cardiff.
76. He knew that he had been referred to a psychotherapist by the psychiatrist
but also understood that she only had a limited appointment capacity and
there was a long waiting list.
77. Sadly, the psychotherapist told my investigators that she would first have
been able to offer him an appointment on Tuesday 13 April when a vacancy
occurred. It is not her usual practice to let prisoners know in advance of an
appointment as disappointments can arise if, for any reason, it is not possible
to go ahead. He would not have known, therefore, that an appointment for
19
counselling was so close. The psychiatrist would also not have known of this
appointment when he met him on 6 April.
78. The clinical review made the following recommendation with regard informing
prisoners about appointments.
The Head of Healthcare should ensure that prisoners and relevant staff
(including other healthcare professionals) are given reasonable advance
notice of forthcoming appointments with healthcare professionals.
79. He was also meeting with his CARATS worker and it is clear from her record
of the meetings and her interview with investigators that, whilst anxious to
have counselling, he appreciated that there would be a wait before he could
begin. She offered to refer him to a bereavement counsellor who would
speak to him more generally but he said he was happy to wait for his referral
through the mental health team.
80. Provision for counselling at Cardiff had apparently been reduced in the year
prior to his death. The psychiatrist showed my investigators a paper for
internal circulation which he prepared in May 2009 and outlined gaps in
mental health provision, including counselling to support distressed prisoners.
He emphasised in interview, however, that he could not say if earlier contact
with a trained counsellor could have prevented him from taking his life. The
chance to share some of the burden of his distressing thoughts, however,
may have given him more peace of mind as he waited to transfer to Parc.
81. Across the prison estate, access to counselling is highly varied. Clear referral
processes and support operate for those with enduring mental health
problems via the mental health in-reach team. However, for a prisoner
presenting with difficulties like his, the opportunities are patchy. Therefore, I
am not minded to make a recommendation but urge the Governor to assure
himself that the provision of counselling is the best that it can be with the staff
and resources available.
82. The clinical review has reached a different conclusion assessing that the
delays he encountered in accessing appropriate healthcare professionals
cannot be regarded as good practice. I do not share this view and believe
that his access to professionals compares favourably to that which is
expected in the community.
The impact of appearing at an inquest
83. When he was first remanded into custody, it was under the shadow of being
investigated for supplying the death of a fellow resident at the YMCA. That
this weighed heavily on his mind in the early months of his time in prison is
confirmed by letters to his mother, the testimony of his friend Prisoner A and
various remarks to prison staff. The possibility that he would be criminally
charged in connection with this death, however, had receded by the time of
his own death.
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84. In his interview with the probation officer, he did not appear to be unduly
affected by guilt about the overdose. He had denied direct involvement and
apparently saw his own activities supplying heroin to other users as a
pragmatic way of funding his own use.
85. My investigators were informed that he would have been called to the inquest
into the death of the hostel resident which was to be held on 16 April. (The
date had been changed from 31 March as this coincided with his original
sentencing date at the Crown Court.) It could not be established whether he
knew this as no official documentation was found in his cell. Prison staff
would not have known either for security reasons as they would normally only
have been told to produce him on the day of the hearing. He did not mention
that he was worried about attending the inquest in the days before he died. It
is not possible, therefore, to conclude one way or the other if his state of mind
was influenced by the prospect of attending the inquest.
Personal officer scheme
86. The success of the personal officer scheme (each prisoner has a named
officer who they see on a regular basis) at Cardiff depends on staff having
time to develop positive connections with the prisoners in their care. When he
was on F wing it would seem that he appreciated the support from the working
relationship forged with his personal officer there. He was not able to stay on
this wing once he was convicted and had to transfer to B wing. Unfortunately,
he had not been on this wing long enough to form supportive relationships
with staff before his last weekend when he was apparently very troubled.
87. I do not believe that any fault should be directed to the officers on B4 landing.
Both officers on duty when he died were highly experienced with many years
service between them. Officer A spoke eloquently in interview about the
hectic demands of dealing with the 46 to 48 prisoners on B4 around that time,
which is typical of the pressures in all local prisons. Although he was aware
later that he was designated as his personal officer, there had been no time
for him to get to know him and build up a professional rapport. Similarly,
Officer B described the morning of his death as extremely busy with many
competing demands on the two officers. Apart from the usual duties, another
prisoner had collapsed and needed medical attention and a particularly
difficult individual was demanding attention from officers.
88. The last HMCIP report encouraged more attention to be given to the personal
officer scheme. That this has happened to some extent is perhaps illustrated
by the quality of the relationship apparently established between him and his
personal officer on F wing. Prisoners on B wing told the investigation team
that staff were approachable and they would have spoken to them about any
concerns relating to him. It is regrettable that he did not have enough time on
B wing to establish a similarly positive relationship with his personal officer on
that wing.
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Concerns raised by the man’s family
The family questioned why the prison did not appropriately address his mental health
needs despite making staff aware of them
89. It is clear that he disclosed the nature of his problems to a number of prison
and medical staff. After his arrival at Cardiff, he was referred to a consultant
psychiatrist and seen within five weeks of this referral. As a non-urgent
referral, the time between the referral and assessment is in line with
community mental health services.
90. Following his mental health assessment, he was not considered to be
mentally ill and his symptoms of PTSD were addressed through medication
and a referral for non-specific counselling from a part time psychotherapist
with a long waiting list. He himself put much of his faith in the prospect of
counselling when he transferred to Parc after sentencing. It is unfortunate
that this facility was not available at Cardiff. It is not possible to know that
whether the intervention would have prevented his death.
He had told his mother that the prison had stopped the medication he had been
prescribed by his doctor in the community to manage his mental health problems.
She questioned the reasons for this
91. The decision to stop prescribing Chlorpromazine to him, as had been the case
in the community, was made after a mental health assessment by a
consultant psychiatrist. He explained to my investigation team that he was
concerned about the long term physical side effects of the medication. The
man agreed to this medical advice and Citalopram, an anti-depressant, was
prescribed instead. When he complained that he felt worse taking this drug,
the doctor agreed to resume the Chlorpromazine.
His mother was aware of her son’s mental suffering at the time of his death and she
felt there was a possibility that he may have been hearing voices. She wanted to
know if there is any evidence of this uncovered by the investigation
92. There is no evidence that he was hearing voices at the time of his death. He
never described this symptom to anyone else although he had a number of
opportunities to do so. His mental health was assessed and reviewed by a
psychiatrist, who did not record the symptom. The last time he saw him was
six days before he died and there was no mention at all of voices. He had not
been reluctant to share his symptoms previously and there is no reason to
think he would have done on this occasion.
93. Similarly, although Prisoner B had a lot to say about matters discussed
between himself and the man during the time they shared a cell, he did not
mention hearing voices.
22
His uncle asked if there had been any concerns about the relationship with his
cellmate
94. The investigation has found no evidence of worrying behaviour towards the
man from his last cellmate. Staff had assessed both men as suitable to share
a cell and there were no concerns expressed either before or after his death.
The prisoner appears to have listened to and comforted him when he
disclosed intimate details about his problems. His response to finding him
was swift and appropriate, as were his actions in helping officers to release
the ligature.
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CONCLUSION
95. Regrettably, it is not always possible to prevent someone taking their own life.
Although the man shared his emotional distress with a number of people
during his time in prison, he never disclosed that he felt so bad that he would
harm himself. There was no occasion, therefore, when staff or other prisoner
was sufficiently concerned about his welfare to open the suicide monitoring
procedures or alert anyone else to his vulnerability.
96. When asked specifically by medical and other prison staff, he always denied
that he was at risk. Crucially, he expressed his distress in a mostly rational
and reasonable way. He was rarely disruptive or demanding and it was only
too easy for him to be seen as quiet and unproblematic. He had only recently
arrived on a busy wing and there had been no time for staff to get to know him
enough to gauge whether his behaviour was unusual or worrying.
97. His cellmate’s account of his last weekend and his emotionally fraught state
suggests that he was struggling. Prisoner A, however, did not recognise that
he was so vulnerable. He chose not to disclose the intensity of his feelings to
anyone else at that time and certainly did not signal that he intended to take
his own life.
98. Although I recommend improvements to blood pressure monitoring,
arrangements for healthcare appointments and record keeping, I do not
believe that they had a bearing on his decision to end his life.
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RECOMMENDATIONS
1. The frequency of blood pressure monitoring should be clearly stated within the
plan of care to ensure that prisoners are monitored correctly, and according to
assessed need whilst undergoing detoxification.
The recommendation was partially accepted.
The man’s blood pressure is documented within the clinical record as follows:
(cid:127) 9 December 2010 in Reception (110/64)
(cid:127) 10 December 2010 on the Clinical Detoxification Prescription Sheet (123/79)
(cid:127) 11 December 2010 (119/84)
(cid:127) 14 December 2010 (117/73)
It is accepted that the frequency of blood pressure monitoring should be clearly
stated in the care plan.
2. The Head of Healthcare should ensure that all records containing information
relevant to prisoners’ health are maintained in accordance with professional
standards, e.g. as stated in the NMC Record Keeping: Guidance for Nurses and
Midwives (2009).
The recommendation was accepted.
Management checks will take place at frequent intervals with feedback to individuals
to ensure standards are maintained.
3. The Head of Healthcare should ensure that prisoners and relevant staff (including
other healthcare professionals) are given reasonable advance notice of forthcoming
appointments with healthcare professionals.
The recommendation was partially accepted.
This would be very difficult to achieve as the Head of Healthcare does not manage
all the healthcare agencies within the prison. In the case of the man the counselling
clinic list is kept by a Clinical Psychotherapist employed by Cardiff and Vale NHS
Trust. It is not her usual practice to let prisoners know in advance of an appointment
as she is of the view that disappointment can arise. There are also some security
reasons why it is sometimes not appropriate to inform a prisoner of appointments
with a healthcare professional. The decision will be made on individual risk
assessment.
25