Individual at Durham

Investigation into the circumstances surrounding
the death of a man at HMP Durham
in March 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2010
This is the report of an investigation into the death of a man at HMP Durham in
March 2009, eight days after he came into custody. He was found hanging by his
cellmate at about 6.30pm and, despite resuscitation attempts, was pronounced dead
25 minutes later. The cause of death was determined by post mortem as hanging.
The senior family liaison Officer (FLO) met with the man’s family at the beginning of
the investigation. I would like to add my personal condolences to those already
expressed on my behalf to the family and friends in Sunderland by the FLO. I must
apologise for the delay in producing this draft report.
My investigator was appointed to investigate the circumstances of the man’s death,
assisted by a colleague. We would like to thank the Governor and his Acting
Governor for the resources they gave the investigation. My particular thanks go to
the liaison officer who assisted the investigation team throughout the process.
We are grateful to the local Primary Care Trust (PCT) for the appointment of an
independent clinical reviewer, a GP from Middlesbrough PCT. He examined the
clinical care that the man received during his short time in custody. His review is the
first annex to the investigation report.
The man was undergoing alcohol detoxification for the first time during his brief time
at the prison. He was referred for further support and a mental health assessment
but neither had taken place before he died. He was found by his cellmate after
association when he stayed alone in his cell.
My report considers the treatment that the man received for his alcohol
detoxification. While I believe it was clinically appropriate, there were few other
measures available to support him through this vulnerable time. I make one national
recommendation to National Offender Management Service (NOMS) about
resources for prisoners going through alcohol withdrawal. I also consider whether
the emergency response was reasonable and make one recommendation about staff
care. I examine the adequacy of the health screening processes for new prisoners
and make two related local recommendations, and one national recommendation to
the Department of Health. Finally, in response to the man’s family’s concerns, I
make one recommendation about visits.
The man was the first of four self inflicted deaths in just over two months at Durham.
The four deaths have been investigated separately, and although there are no
obvious similarities between his death and the three others, the investigation team
has liaised with other investigators to share the lessons learnt.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman July 2010
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CONTENTS
Summary
The Investigation Process
HMP Durham
Key Events
Issues
Conclusion
Recommendations
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SUMMARY
The man was remanded into the custody of HMP Durham on 4 March 2009, charged
with threatening to kill a family member. At 48 years old, he had been in prison
before, but not for a nearly 20 years.
During his initial health screen, the man told staff that he was dependent on alcohol
and misused drugs. He said that he was prescribed medication for depression in the
community. A routine urine sample indicated that he had heroin, benzodiazepines
(anti-anxiety medication), and cannabis in his system. (In fact, the test determined
that the presence of opiates in the blood and the positive heroin result were caused
by the prescription drugs and he had not used heroin.) Following the screen, he was
referred to the doctor and for detoxification. The doctor assessed him in reception,
and referred him to the substance misuse nurse for clinical detoxification for alcohol.
The doctor made a routine mental health referral so that his depression could be
assessed.
The doctor in reception requested the man’s medical records from his community
practice. Although the request was made, it was not followed up and the medical
records were not received at Durham until after his death. The routine secondary
health check he was due in the days after his arrival at Durham did not take place
due to an administrative error.
The man spent a week on the first night centre. He collected his medication from the
nurse stationed at a treatment hatch on the wing three times a day. The nurses who
administered the treatment remembered how polite and friendly he was during their
brief contact with him. They were not required to physically examine him, but
noticed no deterioration in his condition during these exchanges.
On 11 March, the man was transferred to the largest residential wing in the prison.
He was located in a shared cell and spent the following day playing cards and talking
with his cellmate. The cellmate left the cell for a period of association at about
6.00pm. (Association is a daily opportunity for prisoners to mix on the wing out of
their cells.) He decided not to come out of his cell and was locked in for the duration
of the association period, a matter of procedure in Durham. The cell door was
unlocked again at 6.30pm when the cellmate returned.
As the officer who opened the door stepped away from the cell, the man’s cellmate
noticed him hanging from the window frame. He shouted at officers to assist, and
the nearby officer ran into the cell. The officer shouted for help from his colleagues
and was joined by another officer. The general alarm was sounded, and a radio call
was made requesting emergency medical assistance. Officers found he was not
breathing and started resuscitation attempts. The emergency response nurses
arrived, followed by a colleague with necessary medical equipment, and they
assisted with resuscitation. A defibrillator was used but it showed no sign of life and
the response nurse called for the doctor. (A defibrillator is a device used to measure
whether there is any activity in the heart that might be restarted using an electric
shock.) The doctor pronounced him dead at 6.55pm.
The man’s clinical detoxification was managed appropriately, although I am
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concerned about the lack of support for prisoners in any prison withdrawing from
alcohol. I examine the accuracy of the first reception healthscreen, especially
relating to urine testing for substance misuse. The man’s medical records were not
received at the prison until after his death, which affected his treatment for
depression. I consider the response to the discovery of him hanging and conclude
that resuscitation efforts were adequate. I also examine the arrangements for the
prison’s contact with his family after his death.
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THE INVESTIGATION PROCESS
1. My investigator was appointed to lead the investigation into the man’s death.
She visited the prison on 20 March to open the investigation. She met the
Governor of HMP Durham at the time, who is now the temporary Director of
Offender Management for the North East.
2. During her visit, my investigator also met the appointed investigation liaison
officer who arranged for her to speak to a member of the Prison Officers’
Association (POA), the Independent Monitoring Board (IMB), the Health and
Safety representative for the prison, a representative of the Staff Care and
Welfare Service, the family liaison officer for the case and the prison’s lead
doctor. The liaison officer provided my investigator with a copy of the man’s
records. Notices were distributed around the prison, inviting prisoners and
staff to contact the investigator with any information relevant to the
investigation. There was no response to these notices.
3. I am grateful to North East Offender Health and the local Primary Care Trust
(PCT) for the appointment of a clinical reviewer to conduct an independent
clinical review into the medical care that the man received during his short
time at Durham. My investigator, the clinical reviewer, prison doctor and a
Registered Mental Health Nurse (RMN) attended a clinical review meeting at
the prison on 7 April 2009.
4. I am grateful to Offender Health’s substance misuse lead for his advice
about urine testing during the first reception healthscreen.
5. My investigator wrote to the man’s cellmate to ask him whether he was
prepared to be interviewed for the purpose of this investigation. There was
no response to the letter. The investigator relied on the information that he
gave in his statement to the police, and I am grateful for their co-operation.
6. The senior family liaison officer, another family liaison officer and my
investigator met the man’s family on 30 April. I would like to thank his family
for their contribution at such a difficult time. The family were concerned
about the way they were told the news of his death. They wanted to know
whether it was normal procedure to lock a prisoner’s cell during the
association period. The man’s sister also told the investigation team about
her attempt to visit him and that she raised concerns about his depression
with officers. I trust this report goes some way to answering the concerns
they raised during that meeting and subsequent contacts with the senior
family liaison officer.
7. The investigator, accompanied by a colleague, interviewed 14 staff in May
2009. Staff who were unavailable on these dates were interviewed by
telephone in the following weeks.
8. My investigator wrote to Her Majesty’s Coroner for Darlington and South
Durham/North Durham Districts to inform him of the nature and scope of my
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investigation. I am grateful to him for providing a copy of the post mortem
report.
9. Following consultation on the draft report, the family’s appointed solicitor
made representations on their behalf that required further investigation. In
particular, a prisoner made a statement about his contact with the man
during his time at Durham and subsequent conversations he had with staff.
This resulted in two telephone interviews with these staff members, which
can be found as the last two annexes to the investigation report.
10. Following the four deaths in Durham between March and May 2009, NOMS
in the North East undertook a thematic review. I am grateful to NOMS for
sharing the report with my office and I refer to it later in the report.
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HMP DURHAM
11. HMP Durham is a local prison that serves courts in the Durham area. As
such, it accommodates up to 981 adult males who are sentenced and on
remand. Prisoners that have used drugs or alcohol are prescribed
detoxification treatment from the substance misuse team.
12. Her Majesty’s Chief Inspector of Prisons carried out a full inspection of
Durham in September 2006. The inspection team found that reception and
first night arrangements were “very good”. They went on to examine the
procedures in place to look after prisoners at risk of suicide and self harm
and found that they were generally of a “good standard”.
13. The Chief Inspector noted that the suicide and self harm policy included
good reference to risk to those prisoners going through detoxification.
However, she was worried that there was no discrete detoxification unit and
that the role of the detoxification officer was not clear. The Chief Inspector
was also concerned about the apparent lack of an alcohol strategy at
Durham. She wrote that alcohol detoxification was seemingly limited to
clinical treatment. Since that inspection, the prison have written and ratified
an alcohol strategy which was in place before the man came into custody.
14. The Chief Inspector also recommended that that there should be an
immediate review by the area manager of practice following death in custody
reports. The inspection team found that recommendations made by the
Ombudsman had not all been implemented and recommended that they
should be so as “a matter of urgency”.
15. During her inspection, the Chief Inspector found that the reception area at
Durham was poorly designed, but that the prison managed well with the
large number of prisoners passing through every day. She also described
“first night and induction services as good” although was concerned that not
all prisoners were offered a free telephone call. (I am pleased to report that
the man received his free telephone call and used the telephone on the night
that he arrived at Durham.)
16. The Independent Monitoring Board (IMB) noted “with concern” the high
number of prisoners going through reception. In their annual report for 2007-
2008, the IMB wrote that such a high number of prisoners risked “increasing
the risk to safety and wellbeing of prisoners and staff”. They particularly
noted occasions when medical assessments could be delayed by the large
number of prisoners arriving at the prison at one time. (Again, I am pleased
to say that the man experienced no such delay during his time in reception
and received two prompt medical screens.)
17. While their report is silent about the effectiveness of prisoner detoxification at
Durham, the IMB noted that providing the mental and physical health
treatment required by such a large number of prisoners passing through the
prison is a “tall order”. Following the inspection report, the IMB also noted
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that the prison’s action plans following deaths in custody were up to date and
being complied with.
18. The man’s death was the first of four deaths between 12 March and 18 May
2009, just over two months. There is little similarity between his death and
the three other deaths, although all four prisoners were affected by drug and
alcohol misuse. However, although the three other deaths were apparently
self-inflicted, they occurred when prisoners were subject to suicide
prevention measures. A thematic review of those deaths on was carried out
by NOMS in the North East. As he was not on suicide watch at the time he
died, his death was not part of the review. The conclusion of the review was
that suicide prevention procedures at Durham did not meet the “rigorous
standards” required by the Prison Service. However, the report also
concluded that “procedural weaknesses identified in the review did not
contribute directly to the prisoners’ deaths”.
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KEY EVENTS
19. After his arrest on 1 March, the man was remanded into the custody of HMP
Durham on 4 March 2009, following an appearance at a magistrates’ court.
His case was referred to crown court due to the seriousness of the alleged
offence.
20. When he arrived at Durham, a Healthcare Officer (HCO) interviewed him for
the first reception healthscreen. (A first reception healthscreen takes place
every time a prisoner arrives at a prison to determine any immediate
physical and mental health conditions that require treatment, substance
misuse matters that need to be addressed, and any risk that the prisoner
may pose of harming himself or attempting suicide.) He told the HCO that
he had been in prison before, 20 years previously. He said that he had been
assessed by a doctor “in the last few months” for depression and was
prescribed Amitryptiline and Codeine Phosphate. (Amitryptiline can be used
as an anti-depressant or, in a lower dose, to manage pain.)
21. When asked about his drinking and substance misuse, the man admitted to
drinking one litre of vodka daily. He said that he took cannabis and cocaine
at weekends. As a matter of routine, a urine sample was taken and tested
during the reception process. The following results were marked on the
record of his first reception healthscreen:
Frequency Amount Last Withdrawing Urine
Used Result
Heroin +-ve
Methadone
Benzodiazepines +-ve
Amphetamines
Cocaine Weekends 2/7 +-ve
Subutex
Other Cannabis +-ve
(‘+-ve’ indicated a positive result)
22. The HCO told the investigation team that a member of the healthcare team
completing the first reception healthscreen would not ordinarily talk to the
prisoner about their urine test results. He said that, despite the man being
recorded as testing positive for heroin, the result only indicated that he had
taken opiates. The man had already told the HCO that he was prescribed
codeine phosphate in the community, which is classified as an opiate and
would be recorded as a positive heroin result. (I consider the
appropriateness of the form’s wording later in the report.)
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23. When prompted to write whether the man had received treatment for mental
health, the HCO wrote “Amitryptiline?”. He explained to the investigation
team that he questioned the man’s response:
“that’s because he couldn't tell me the correct dose he was on so I
question marked that, and that’s to be checked out later with his GP
when we confirmed his medication”.
24. As required, the HCO asked the man if he had ever harmed himself. The
man explained that he had attempted to overdose 18 months previously but
that he had no more thoughts of self-harm. Assessment, Care in Custody
and Teamwork (ACCT) is the suicide prevention system used by NOMS to
identify and support prisoners who are at risk of suicide or self harm. The
HCO did not open an ACCT document following the reception healthscreen.
25. The healthscreen form requires an explanation if a prisoner has a history of
self-harm, but no ACCT is opened. Under this section, the HCO has only
written “No”. During interview for this investigation, he said he would
ordinarily have written “no, okay now”, and could not remember why he had
not written a fuller statement. Although he could not specifically recall the
man’s healthscreen, he told the investigation team that he finds that
prisoners are honest about thoughts of self harm. He takes other things into
consideration when making his assessment, for example: “Is he giving you
any eye contact, how is he speaking to you? Is it monotone his speech? Is
he constantly up and down?”
26. The HCO referred the man for detoxification treatment and to be assessed
by a doctor. The HCO did not make a mental health referral, despite the
man indicating that he was receiving treatment in the community for
depression. During his interview for the investigation, he explained he
understood that the man was receiving mental health treatment from his GP
in the community, rather than from acute mental health services, for
example, a psychiatrist. Therefore, he concluded that the man’s mental
health needs were not acute and could be effectively dealt with by the prison
doctor.
27. The man was assessed by a doctor in reception, following the first reception
healthscreen. One of the prison doctors works in a nearby community GP
practice, as well as working at the prison for the last five years. Along with
two other local GPs, he visits the prison on weekday evenings to assess
prisoners who have been referred to the doctor. He read the man’s first
reception healthscreen and spoke to him about his substance misuse. He
told the doctor he drank a bottle of vodka and 12 cans of beer every day and
he had used diazepam, cannabis and cocaine since he was a teenager.
28. By the time of the doctor’s assessment, the man had not drunk alcohol or
taken drugs for two days as he had been in police custody prior to arriving
into prison. The doctor noticed that he was “not ill, looks much older than his
years, fine tremor of fingers”. He told the investigation team that the tremor
“was probably not related to drug dependence, but related to a drug,
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particularly benzodiazepine withdrawal, alcohol withdrawal”. He went on
explain that some people going through alcohol withdrawal “look extremely
unwell and very irritable and can fit, [the man] did not fit into that group”.
29. The doctor agreed with the HCO that the positive heroin result did “not imply
he’s used heroin at all”. It was his experience that prisoners who take heroin
would “have no reluctance” to talk about the extent of their problems. He did
not ask the man about his positive urine result, but understood it to mean
that he had used either codeine or dihydrocodeine (both opiate-based
painkillers).
30. The man told the doctor that he had been diagnosed with depression but
described his mood as “okay now”. He also spoke about his attempt to take
an overdose 18 months before. The doctor referred him for a mental health
assessment because of his history of self harm, so that the diagnosis of
depression could be further explored.
31. The administrative assistant for the mental health team explained to the
investigation team that a routine mental health assessment could take
between six and eight weeks to complete, depending on the availability of
staff. An urgent mental health assessment can take place within 24 hours.
When asked why he did not make an urgent referral, the doctor said:
“I didn’t feel that it was anything that was desperately urgent. Although
I have identified that there is a mental health issue, I didn’t feel that
there was a particularly urgent mental health issue there … I didn’t feel
that he needed to be seen by the mental health people the next day.”
The doctor confirmed that he understood that a routine mental health referral
would take longer and he was happy for that to be the case.
32. The doctor asked for the man’s medical records to be retrieved from his
community practice to confirm his diagnosis and medication. (In fact, the
medical record showed no recent diagnosis of depression.) The doctor
understood that such a request would be processed by administrative staff in
the healthcare centre at the prison. When asked why he had put this
instruction in capital letters, the doctor told the investigation team:
“I think that was to draw particular attention to it. I think because I felt
we needed to know what the history was of the overdose and any other
psychological history.”
(Despite the doctor’s clear, capitalised instruction, the man’s medical
records were not received at Durham until after his death eight days later.)
33. Telephone records show that the man spoke to a family member later that
afternoon. (Every prisoner must be given the opportunity to use the
telephone on their first night in custody.) The transcript of this conversation
shows that he asked his relative to find the telephone number of his alleged
victim, so that he could speak with them and get the charges dropped. Upon
12
hearing this, an officer, who was monitoring telephone calls for security
purposes, raised a Security Information Report (SIR). Details of the
telephone call were passed to the prison’s police liaison officer and it was
decided that no further action was required. During a further short telephone
conversation that afternoon, the alleged victim refused to visit the man.
34. The next day, 5 March, the administrative assistant requested the man’s
medical records from the surgery in the community. The request was sent
by fax, requesting an immediate faxed response. The Healthcare
Administrative Manager for Durham explained that records that are not
received within two clear working days of the request are usually followed up
by the administrative assistant, in this case the administrative assistant.
Unfortunately, 5 March was a Thursday and the administrative assistant was
on leave for the following week. During this time, the prison’s computer
system failed which added to the confusion and the man’s records were not
requested again.
35. Later that day, a Registered Mental Nurse (RMN) met with the man to
discuss his substance misuse needs. The RMN is the substance misuse
nurse appointed for Durham. The nurse discussed alcoholism with him, and
the man repeated that he had started drinking from a young age. He said
that he had not previously tried to stop drinking. During his assessment, he
said that he was experiencing stomach cramps and mild tremors, which are
signs of withdrawal. The RMN described the man as “bright, pleasant,
chatty and jovial in mood”, during their conversation. The nurse prescribed a
clinical detoxification, starting on 40 milligrams (mg) of Chlordiazepoxide and
decreasing over the ten day clinical detoxification.
36. Despite recording that the man had intentionally overdosed twice (in 2007
and 2008), the RMN also wrote in his records: “no past history of self harm
and no suicidal ideation expressed at any time of assessment”. He told my
investigation team that he is confident about ACCT procedures and would
have opened an ACCT document if he had any concerns, but there was
“nothing whatsoever”.
37. The RMN did not record any information about the man’s urine testing
positive for heroin. He told the investigation team that he did not ask him
about the result, because he understood that it indicated simply that the man
had codeine in his system, not necessarily heroin. He said that prisoners
who are withdrawing from heroin need a high level of support and are not
reluctant to tell staff about their use of the drug and consequent
detoxification needs. Despite not asking directly, the RMN was satisfied that
the man was not a heroin user, judging by the way he presented himself.
38. That afternoon, a CARATS worker completed a CARATS assessment with
the man. (CARATS stands for Counselling, Assessment, Referral, Advice
and Throughcare Services and is the service used nationally to support
prisoners with substance misuse needs.) Every prisoner at Durham meets a
member of the CARATS team as part of their induction process to establish
whether they have any substance misuse needs. She remembered that he
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was positive about the detoxification programme. He said it would help him
to stop drinking for the sake of his children and marriage. The CARATS
worker described his alcohol use as “heavy”, but was impressed at his
honesty. She assesses the risk of self harm in each of the prisoners she
meets. He told her about his attempt at overdose 18 months before. He
said that he was stopped in his attempt by a friend who reminded him that
his children needed him. He told her that he had no thoughts of self harm
and she recalled to my investigation team that “he seemed perfectly honest,
I had no reason to doubt him”. The CARATS worker devised a care plan,
including group sessions and one to one work. Sadly the man died before
he had the opportunity to access any of these services.
39. Two friends visited the man on the morning of 6 March. He spent the next
few days on the first night centre, completing the induction programme and
learning about the rules and regime of the prison. He collected his
detoxification medication three times a day from the treatment hatch on the
wing. Nurses described the process to the investigation team. The
medication is dispensed from the pharmacy and taken to the wing. Each
prisoner waits in line for his medication in the morning, at lunchtime and in
the evening. When the prisoner reaches the front of the queue, he steps
forward out of the line towards the nurse. Although there is no physical
barrier, the nurses told the investigation team that the exchange between
nurse and prisoner is private due to the distance between the queue and the
treatment hatch. Nurses do not carry out a physical examination of the
prisoner when they dispense medication, but they look for signs of
deterioration in someone’s condition. The nurses could not remember
noticing anything concerning about the man’s presentation. They recalled
his politeness and humour in the brief exchanges they had three times a
day.
40. On Sunday 8 March, the man’s sister tried to visit him but was refused entry
by staff in the visits area. She told the senior family liaison officer from this
office that she arrived at 9.00am and waited for half an hour, before being
told he was not allowed another visit. She recalled speaking to a male and a
female officer in her efforts to visit her brother. The investigation team spoke
with two officers who worked in the visits area that day. Neither of the
officers recalled speaking to the man’s sister. The man’s sister told the
senior family liaison officer that she mentioned her brother’s depression to
the officers and asked them to start suicide prevention measures. Neither
officer recalled that conversation. Both told the investigation team that they
would have contacted the wing to pass on any such concerns, and open an
ACCT document if appropriate.
41. The man was due to have a secondary health check on 10 March. (This is a
physical health check, similar to that received in the community when a
patient joins a community practice.) Due to staff shortages the Primary Care
team leader was tasked with completing the secondary health checks that
day. It would not normally be her role. She visited the prisoners’ cells and
took basic observations, for example the prisoner’s blood pressure.
However, when she reached the man’s cell, he had been taken to court and
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she could not complete the health check. She indicated that he was at court,
but also noted in error that she had assessed him. (If a prisoner is
unavailable for the secondary health check, they would normally be added to
the list for the following day.) Due to her error, he was not added to the list
because the form showed that he had already been assessed.
42. The medication required for the man’s clinical detoxification was taken to
court by staff, so that he could continue his treatment. His family told the
investigator that he had thought an appearance from his alleged victim would
have led to his release that day. The alleged victim did not appear in court.
He was remanded back to custody and his case was committed to crown
court.
43. After the draft report was issued, the family provided a statement from
another prisoner who was at Durham at the same time as the man, who was
also a family friend. (My investigator wrote to the prisoner during the course
of the investigation but did not receive a response.) In his statement, the
prisoner said he was at the magistrates’ court on the same day as the man.
He was worried that the man was upset about his personal circumstances
and, although the man did not mention suicide or self harm, the prisoner
described him as “clearly in a distressed state”. When they got back to the
prison, the man and this prisoner ate together in the reception area before
going back to their different wings. The prisoner was located on D wing and
the man returned to the first night centre.
44. In his statement, the prisoner wrote that he spoke to an officer about whether
it would be possible to arrange for the man to transfer onto D wing, “where
he could keep an eye on him”. The prisoner told the investigator that he said
to the officer that he did not want the man “to become another statistic”, by
which he meant that he was at risk of suicide. The prisoner said that he also
spoke to a SO on the same day and again asked whether the man could
transfer to D wing. The prisoner said he used the same expression to
describe his concern that the man was at risk of suicide. When my
investigator spoke to them, neither the officer nor the SO remembered
having such a conversation with the prisoner in question.
45. The following evening, the man was transferred from the first night centre to
A wing, the largest wing in the prison. He was located in a shared cell on the
second level.
Thursday 12 March
46. In his statement to the police after the man’s death, his cellmate said they
spent the following day together in their cell watching television and playing
cards. The man spoke openly about how his “head was in bits” due to his
personal situation. They ate their lunch together in their cell and ordered
their meals for the next day. His cellmate noticed that the man wrote a letter
that afternoon. He told the police that there was nothing in his behaviour or
their discussions that made him think that he would kill himself.
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47. The man collected his medication, 10mg chlordiazepoxide, at 4.00pm that
afternoon. A nurse was at the treatment hatch. During interview with the
investigation team, she remembered having seen him that day. She
explained that when administering treatment, she would assess a prisoner’s
physical appearance and their presentation to ensure that they could take
their medication safely. She did not remember anything that caused her
concern about him on that occasion.
48. Prisoners are allowed out of their cells for an hour long period of association
at about 6.00pm every other evening. During this time, they can shower,
use the telephones and mix with other prisoners on the wing. Prisoners who
do not associate are locked in their cells to prevent other prisoners from
going into their cells and minimise opportunities for bullying. The man’s
cellmate left the cell for association, but he preferred to stay in his cell. An
officer unlocked their cell and looked in when the man’s cellmate left for
association. He said he noticed “nothing untoward”. In his section of the
wing, the cell doors automatically locked when they were closed. The man
was locked alone in his cell, with the observation panel on the door shut.
49. The officer was standing outside the showers with another officer during the
association period. He was observing the shower area and taking prisoners
back to their cells on the second landing. He was also observing the
telephones located on either side of the door to the man’s cell. During
interview for this investigation, the first officer told the investigation team that
he did not hear anything “untoward” and prisoners did not alert him to
anything happening in the man’s cell during that time.
50. The man’s cellmate approached the first officer and asked to be taken back
to his cell at about 6.30pm. The officer had to continue to monitor the
showers with the second officer as well as escort the man’s cellmate. The
officer unlocked the cell door and looked behind him to the shower area.
The cellmate went into the cell. The officer heard a scream. He saw that the
man was hanging from the window with a torn bedsheet used as a ligature
around his neck. The cellmate was moved to another cell.
51. The sequence of events over the next five minutes is confusing. The officer
shouted the word “staff” for assistance and the second officer ran to the cell.
The first officer thought that the second officer pressed the general alarm as
he ran past it on the wing, but the second officer assured the investigation
team that he did not do so. He said that he carried a radio, but did not use it.
The first officer thought that neither officer had a radio that day, because
their duties did not demand it. Instead, they depended on the general alarm
to get assistance from staff. (A general alarm is used to alert staff to
incidents on the wing where staff assistance is required.)
52. The first officer went into the cell and supported the man’s weight. The
second officer followed him into the cell. Using the anti-ligature knife that he
carried on his belt, the second officer cut the bed sheet and helped the other
officer to lower the man to the ground. Once they had laid him on the
ground, the first officer went to the door to see if healthcare staff were on
16
their way. The second officer checked whether the man was breathing and
looked for a pulse on his neck. He found no signs of life, and started mouth
to mouth resuscitation.
53. A third officer was nearby and heard the alarm. During interview with the
investigation team, he said it took around 15 seconds to get to the cell. On
arrival, he called a “Code Black” over his radio. (A Code Black is used when
a prisoner is unconscious and alerts healthcare staff that they are needed.)
At the same time, two officers from the Safer Custody team arrived. The
fourth officer also made a Code Black radio call. The fifth officer took over
mouth to mouth resuscitation from the second officer and the fourth officer
started chest compressions.
54. A nurse was the emergency medical response nurse that day (known as
‘Hotel One’). She was assisting the doctor in the reception area of the
prison, next door to A wing, where the man was located. She heard the
general alarm. During interview for this investigation, she told my
investigator that a general alarm usually means that a fight is taking place.
Medical assistance is often required after such an incident, so she
suggested to the doctor that they wait where they were, in case they were
needed.
55. Shortly after hearing the general alarm, Hotel One remembered hearing the
location of the emergency over the radio as being on the second landing of A
wing. She said she still thought it was a fight because the location meant
that the incident was near the central staircase, which is a busy area where
there can be a lot of fights. A second radio message requested Hotel One.
She told my investigation team that she did not hear a Code Black message.
She said if she had heard a Code Black, she would have known that a
prisoner was hanging. Instead, she made her way to the emergency,
without knowing. She reached the man’s cell around three minutes after the
general alarm was raised. She requested emergency equipment and for an
ambulance to be called.
56. A second nurse heard the Code Black call and knew that medical equipment
needed to be taken to the cell. She was designated to take equipment to
any emergency that day. She took the emergency grab bag and the
defibrillator. By the time she reached the man’s cell, Hotel One had checked
his breathing and pulse and assisted with chest compressions. The nurse
arrived and set up the defibrillator. The advice from the defibrillator was not
to administer an electric shock to him and so resuscitation attempts were
continued.
57. An (Acting) Senior Officer (A)SO was the manager of A wing that day. She
heard the general alarm while she was on the fifth floor of the wing. By the
time she arrived at the cell, Hotel One and the nurse had taken control of the
situation. During interview for this investigation, the (A)SO estimated that it
took her five minutes to get from the fifth landing to the second landing. She
said that it took a long time because she had to make sure that prisoners
were returned to their cells. She explained to the investigation team that her
17
priority was to ensure that no prisoners could look in the man’s cell. The
A(SO) also spoke to the staff involved to support them and encouraged
those who no longer had a role in the emergency response to move to a
quiet area.
58. The Hotel One response nurse and another nurse continued their
resuscitation attempts. The response nurse asked that the doctor be called
from E wing to assist. The doctor reached the cell before the ambulance
had arrived. He pronounced the man dead at 6.55pm.
59. The man’s family told the senior family liaison officer that a prisoner was on
the telephone as the events unfolded and knew that the man had been found
hanging. This prisoner told the person he was speaking to, and a rumour
started in the man’s local area about his death. The (A)SO agreed that this
was regrettable but in practice difficult to prevent. She told the investigation
team that there were no telephones in the area. The investigator visited the
man’s cell and saw the telephones located on either side of the door.
Prisoner Support
60. After the man’s death, the (A)SO broke the news to the cellmate about what
had happened. He was given a drink and some tobacco and they had what
she described as “a lengthy chat”. She offered the prisoner access to the
Samaritans and a Listener. (Listeners are prisoners trained by Samaritans
to provide confidential emotional support to fellow prisoners in distress.)
Also, he was moved to a cell with a friend for extra support. A Principal
Officer (PO) from the Staff Care and Welfare Service also visited the man’s
cellmate to check on his wellbeing.
61. The (A)SO spoke to another prisoner on the wing, who had been identified
as at risk of self harm, in line with prison procedure.
62. All the prisoners were offered support from the Listeners and the chaplaincy.
Family Contact
63. Durham’s Family Liaison Officer (FLO), a Senior Officer (SO), was contacted
at 8.00pm on 12 March and told about the man’s death. The police advised
the FLO to have an escort when breaking the news to the family.
Arrangements were made for the FLO to meet the police at a police station
local to the man’s family in order to visit the man’s wife and notify her of his
death. The FLO’s records show that she followed the police to the home
address at 11.30pm. The man’s daughter was there and told the police and
the FLO that her mother was not at home. The daughter contacted her
mother on her mobile and told her that staff from Durham prison were there.
After half an hour, just after midnight, the police were told that the man’s wife
would not be available that evening. They took the decision to return the
following day.
18
64. The FLO contacted the Probation Service the following morning, 13 March,
to find out further information about the man’s next of kin. The police were
contacted again and advised that they would notify the man’s wife in person.
The FLO briefed the police about the circumstances of the man’s death and
asked that his wife be given her contact details to speak to her after the
police visit. At 11.25am, following the police visit, the man’s wife telephoned
the FLO, who told her in more detail about what had happened to her
husband. She made no further contact with the prison until she collected his
personal belongings some weeks later.
65. One day later, on 14 March, the man’s mother, sister and a friend went to
the prison and met the Governor. The Governor met them at the gate of the
prison and brought them in to meet the FLO. They told the FLO that they
were unhappy that they did not hear about the man’s death until the day
afterwards. The FLO explained that it is prison procedure to notify the listed
next of kin before notifying anyone else of a prisoner’s death. The senior
officer had been unable to speak to the man’s wife on the evening of his
death, so it was not possible to speak to other members of his family until
the following morning. The FLO made arrangements to visit the man’s
mother and sister at their home.
66. In line with normal procedure, the prison FLO checked with the prison’s
police liaison officer about any security issues regarding visiting the family in
their home. She was advised that officers should not visit the address and
should arrange for the visit to be held elsewhere. On 17 March, the FLO
telephoned the man’s mother and spoke to his sister. The FLO asked
whether the family would consider meeting at the prison, but they refused
this offer. The family preferred to meet at their home address, but following
police advice, the FLO proposed an alternative venue. The family also
asked that a representative from the prison attend the funeral. Again, the
police advised the prison not to attend and said that the prison’s attendance
would require extra police resources. The FLO explained this to the man’s
sister. Eventually, the FLO agreed with the man’s sister that there would not
be a representative from the prison at the funeral but that she would contact
her afterwards to arrange to meet at a local hotel. This meeting went ahead
on 27 March, attended by the man’s mother, brother and two sisters. The
FLO recorded in her log that the meeting served to “give the man’s family the
truth and reassure them” and she offered to answer any queries should they
want to contact her in the meantime.
67. According to the prison’s family liaison log, the man’s wife attended the
prison and collected his property on 8 May. She thanked the family liaison
officer but explained that she wanted no further contact.
68. On 15 June, the man’s sister contacted the prison and spoke to the FLO at
length. She wanted an update on the situation, including the progress of the
Ombudsman’s investigation. The FLO told her that the Ombudsman’s
investigation was being conducted independently from the prison and she
encouraged the man’s sister to contact our office directly. The man’s sister
had expected the prison to maintain contact. The FLO explained that she
19
would not normally be in touch with the family, but would answer any queries
should they want to know anything about the prison or the man’s time here.
Another sister joined the conversation and said that the family were unhappy
that contact had not been maintained by the prison. According to her log,
the FLO said she would be happy to arrange another meeting if the family
would find it helpful, but the conversation deteriorated and ended. There are
no further entries in the family liaison log.
69. The family told my senior family liaison officer that they were upset that they
had not heard anything from the prison. The investigation team has
examined the family liaison log and spoke with the prison FLO at the
beginning of the investigation process to consider their concerns. NOMS
offers guidance on how to conduct family liaison, entitled “Liaison with
bereaved families following a death in custody guidance”. It advises that it is
the role of the family liaison officer to maintain contact with the family up
until, and sometimes after the inquest. However, the guidance also explains
that the FLO role is not a counselling role. It describes the FLO as the
family’s main point of contact in the prison to deal with any queries.
According to her log, at the meeting on 27 March, the FLO told the family
that they were welcome to contact her with any queries. There was no
further contact from that part of the family until June. There is no evidence
that the family tried to contact the FLO in the meantime, or vice versa.
70. I am disappointed that the prison’s relationship with this family has broken
down. The sensitivities around breaking the news, the first visit and the
funeral were unavoidable given police advice, but nonetheless must have
been upsetting for the man’s family. It is unfortunate that the family were not
clear about the FLO’s role following their meeting on 27 March. I do not
think it unreasonable that the prison FLO did not contact the family after that
meeting, because she was waiting for the family to contact her with any
questions.
71. There were four deaths in custody at Durham over a two month period. The
investigation teams have examined the family liaison in all four cases. The
arrangement was the same in those cases, in that the family were asked to
contact the prison when necessary but were otherwise not contacted by the
prison after the funeral took place. I understand that the man’s family would
have liked to be contacted by the prison. In some cases, contact from the
prison without cause could be perceived as an unnecessary intrusion. I
hope that the Governor will ensure that future family liaison arrangements
are clearly understood by the family from the outset.
Staff support
72. The (A)SO told staff to gather in her office when they were no longer needed
to attend to the man. She spoke with those involved and checked their
welfare. The orderly officer who managed the prison that day attended the
man’s cell in that capacity, but afterwards was available to provide support
for staff on the wing. At 7.15pm, staff participated in a hot debrief, to give
them the opportunity to discuss what happened and raise any concerns.
20
73. A further debrief meeting was held by the Head of Safety and Decency on 18
March 2009. Again, staff involved went through what had happened. The
orderly officer thanked all those involved in the response efforts for their
“excellent team working skills and professional conduct”.
74. Unfortunately, Hotel One, as the emergency nurse for her shift, was called
straight to another emergency so could not attend the hot debrief. It is
regrettable that she had no time to recover from the man’s death. It is also
regrettable that no healthcare staff attended the debrief on 18 March. I
expect the critical role played by healthcare to be recognised by the prison. I
hope that healthcare staff are encouraged to participate in opportunities to
debrief after serious incidents.
The Governor and the healthcare manager should that ensure
healthcare staff attend future debrief meetings after a death in custody.
21
ISSUES
Clinical care
75. The clinical reviewer was appointed by the local PCT to conduct a review
into the clinical care the man received during his short time at Durham. He
reviewed the man’s medical records and met healthcare staff at the prison,
alongside my investigator. Despite being unable to interview jointly staff with
the investigation team, he saw all the relevant transcripts and notes of
interviews to inform his review.
76. The clinical reviewer makes four recommendations in his review, which I
endorse and refer to in the following sections. As well as identifying lessons
that could be learned, the clinical reviewer also recognised good practice. It
was his view that the prison “demonstrated efforts to ensure that prisoners
with alcohol and drug problems are dealt with appropriately by trained
professionals”. (I discuss this in more detail below.) He also describes
resuscitation efforts by healthcare professionals and officers as “exemplary”.
I will discuss his findings, along with my own, in the following pages.
Alcohol detoxification
77. The man told staff that he drank a litre of vodka and 12 bottles of beer a day.
This was described by his CARATS worker as a “heavy” use of alcohol.
Nevertheless, the prison doctor and the RMN, the substance misuse nurse,
did not notice serious signs of alcohol withdrawal. The man told the RMN
that he had never tried to stop drinking before. He then told the CARATS
worker that he was pleased to be undergoing detoxification for the sake of
his children. All the staff thought that he was honest about his substance
misuse and genuinely wanted to stop drinking.
78. The man began the alcohol detoxification programme on 4 March. The
clinical reviewer considered that the clinical treatment he received was
appropriate to his needs. He was located on the induction wing for the
majority of his time at Durham. This is in line with the prison’s local Alcohol
Management Strategy. However he was transferred to the larger ‘A’ wing on
11 March before the detoxification programme had been completed. No
prison staff on that wing were aware that he was on a detoxification
programme although he was being monitored by nursing staff when he
collected his medication three times a day.
79. The clinical reviewer noted that the man was assessed by a trained
substance misuse worker and mental health nurse and also by a member of
the CARATS team who offered intervention, assessment and counselling.
He concluded that this demonstrated the prison’s efforts to ensure that
prisoners with alcohol and drug problems are dealt with appropriately by
trained professionals.
80. I am however concerned about the lack of both psychological and social
support for prisoners going through detoxification. I understand that there
22
are limited national resources in this area. I am pleased that Durham has
now introduced an Alcohol Strategy following the inspection from HMCIP in
2006. However, the document is limited to the clinical care, and still does
not discuss the psychological needs of prisoners going through such a
traumatic time.
81. The CARATS representative carried out an excellent substance misuse
assessment, however there were little resources available for further
support. I do not doubt that the man would have received support from
CARATS through one to one sessions and group work in due course, should
he have lived. I am concerned that so little was available to him throughout
his detoxification which was nearing the end. In other investigations, the
Ombudsman has found that when an individual ends the detoxification
process, feelings masked by the use of illicit substances can be felt more
strongly, and the reality of their situation becomes even more apparent. This
makes the need for additional support even more important. This problem is
not specific to Durham and it is imperative that efficient clinical detoxification
is accompanied by support for prisoners to address the problems that might
have led to their drinking.
82. Alcohol withdrawal affects a significant number of the prison’s population. In
other investigations that this office has undertaken in prisons throughout
England and Wales, I have commented on the lack of resources for
prisoners going through alcohol withdrawal before. This is the not the first
time I have made this recommendation and I am concerned that I must
repeat it again:
NOMS should consider allocation of funding to support the
considerable number of prisoners going through withdrawal from
alcohol in prison.
I agree with the Chief Inspector’s finding that additional support is often
easier when it is delivered on a specific unit. Staff on the unit where the man
died were not aware he was withdrawing from alcohol. When prisoners
going through detoxification, whether from alcohol or drugs, are located on
one unit, specific interventions are more easily delivered, and non-clinical
staff are aware without breaching medical confidentiality.
First reception healthscreen
83. The HCO who carried out the man’s first reception healthscreen on 4 March
was an experienced member of staff and referred him to the substance
misuse team and to the doctor. (I will discuss the positive heroin result
below.) As part of the assessment of the man’s mental health, the HCO
asked him whether he had ever self-harmed before. The man said that he
had taken an overdose 18 months previously. If the member of staff does
not open an ACCT document, even when a prisoner has self-harmed before,
the form requires an explanation. In this section, the HCO has written, “No”.
When asked about this entry during interview, he said he would usually write
23
“no, ok now”, but could not remember why he had not done so on this
occasion.
84. The man also told the healthcare officer that he had received treatment for
depression from the doctor. Given his history of self harm and reported
treatment for depression, the HCO was required to refer him to the mental
health service. The emboldened instruction is clearly marked on the first
reception healthscreen form. When asked why he did not make a mental
health referral, the HCO said that he thought the man’s mental health could
be appropriate treated by the doctor. In this case, the man was assessed by
the doctor on the day of his arrival. The doctor referred him to the mental
health team, so there would have been no delay in his mental health being
assessed. Nonetheless, I am concerned that the HCO did not follow the
clear instruction on the healthscreen form.
The Head of Healthcare should remind staff of the importance of
following the clear requirements of the first reception healthscreen.
Mental health referral
85. The doctor made a routine mental health referral. He told my investigation
team that “it does not usually take weeks” for a routine mental health referral
to be processed. However, the healthcare administrator told the team that it
can take between six and eight weeks for an assessment to take place.
86. The man told the HCO and the doctor that he had been diagnosed with
depression and was receiving treatment for it. He was being prescribed
Amitryptiline, which can be used as an anti-depressant. However, the dose
that he was taking was too small to be an effective anti-depressant and was
instead being prescribed for pain relief. His medical records, retrieved from
his community practice after his death, show that he had not been diagnosed
or treated for depression in recent years. I will discuss the retrieval of his
medical records below.
87. The doctor told the investigation team that he made the mental health
referral because of the history of depression and the man’s previous attempt
at suicide. He did not consider him at risk of self harm, taking into
consideration his body language at the time of his examination. The doctor
thought it was “prudent” to make the referral, and described it as a
“precaution” during his interview for this investigation. He seconded the
HCO’s referral to the substance misuse team, and was assured that his
needs would be met there as far as detoxification. I agree with the doctor
that a routine mental health referral was appropriate given the information
available at that time.
Positive heroin result
88. As part of the first reception healthscreen, the man’s urine was tested for
illicit substances. Amongst other substances the healthscreen document
was marked that his urine contained traces of heroin. All of the clinical staff
24
interviewed by the investigation team understood that of a positive heroin
result did not necessarily mean that the prisoner had taken heroin, and it
could mean he had taken an opiate based medication. However, the form
itself is misleading as it quite clearly states that the positive finding is for
heroin not opiates. His result reflected the codeine that he was taking for his
arthritis.
89. The investigation team contacted the Department of Health’s section head
for substance misuse to confirm how the urine test could be interpreted. He
agreed that any opiate would show in a routine urine test and could be
recorded as a positive heroin result. However, he told the investigator that
any positive result should be discussed with the prisoner. It is likely that staff
were correct in their assumption that the man had not taken heroin, given he
did not present symptoms of withdrawing from drugs, although he did appear
to be withdrawing from alcohol. However, I share the clinical reviewer and
the section head’s concerns that the positive result was misleading and was
not followed up by staff.
The Governor has accepted that the record heroin was present was not
correct. He advised that they are looking at ways to improve the recording of
first reception health screen results to more accurately reflect the information
that they have. I agree with the clinical reviewer that, if possible, the urine
test should discriminate between heroin and prescription opiates. With this
in mind, I repeat the clinical reviewer’s recommendation:
The Department of Health should consider revising the urine test at
reception to discriminate between heroin and prescription opiates.
Missed secondary health check
90. The man was due to have his secondary health check on 10 March and the
primary care team leader visited his cell on the induction wing to carry it out.
However he had been taken to court by the time she arrived. The nurse
marked in the records that she had seen him although she had not.
Therefore, a follow up appointment was not booked for the following day in
line with normal procedure. As discussed above, the clinical reviewer shares
my view that the second health screening gives an opportunity to the
medical department at the prison to review and assess the patient again.
The Head of Healthcare should devise a system to audit whether
prisoners have received a secondary healthscreen.
Community medical records
91. The doctor’s request for the man’s records was written in capital letters.
Although they were requested by fax on 5 March from the surgery, they were
never received. My investigation team were told that missing records were
normally followed up within 48 hours. The administrative assistant went on
leave before the 48 hours had elapsed. No one covered her role in her
25
absence, so the community practice was not contacted when the records did
not arrive until after the man’s death.
92. I agree with the clinical reviewer that this is not acceptable. In the man’s
case, staff were not aware that he had not been diagnosed with depression
or that he had not complied with his medication in the community. The
investigation team interviewed the Head of Healthcare Administration who
acknowledged that the system for retrieving records had failed in this
instance.
93. I am pleased to report that Durham has improved its systems by using a
database system to request records. This is a system which can be
accessed by any member of the healthcare team meaning that outstanding
requests for patients’ medical records are monitored more closely and efforts
are being made to improve communications with practices in the community.
Given the improvements, I am not minded to make a recommendation in this
matter.
Emergency response
94. The two officers who were closest to the man’s cell when he was discovered
hanging were not carrying radios because their duties did not require it. The
second officer thought he was carrying a radio that day, but records show
that his duties did not require it. The first officer remembered that neither
officer had a radio with them at the time of the emergency. On balance, it is
unlikely that the second officer was carrying a radio.
95. Although no one is clear who raised the general alarm, it was probably
raised before the Code Black radio call was used. Although it is prison
procedure to use a radio code system to communicate the nature of the
emergency, the use of the general alarm had the intended effect of getting
assistance to the man. I do not think the use of the general alarm
unnecessarily delayed the emergency response.
96. The Hotel One response nurse heard the general alarm and then heard the
request for medical assistance. She told the investigation team that she did
not know the nature of the emergency because she did not hear the Code
Black radio call. The investigation team spoke to several staff who attended
the man’s cell that day and they all recalled the Code Black radio call being
used, albeit after the general alarm was sounded. Hotel One was nearby
and had waited for further instruction when she heard the general alarm.
The collection of medical equipment was not her role, but the role of the
nurse that day. I do not think that Hotel One’s confusion delayed her
response to the emergency situation. The medical equipment was brought
by the nurse within minutes of the alarm being raised. Neither do I think that
confusion about the nature of the emergency delayed the man’s access to
emergency medical care.
97. However, I am surprised that the (A)SO took so long to reach the man’s cell.
I understand that she did not know what had happened when the general
26
alarm was raised. When a general alarm is raised, officers must ensure
prisoners are taken back to their cells immediately to allow staff to deal with
the emergency, stop the prisoners using phones, and preserve the dignity of
individuals in need of attention. I also appreciate that it can be difficult to
estimate how much time has passed during an emergency situation.
However, I expect the senior officer of a wing to assist in an emergency
situation on their wing as a matter of priority and delegate this task to
officers.
98. It is unfortunate that so much confusion surrounds the sequence of events
after the man was discovered. However, I agree with the clinical reviewer
that the resuscitation efforts carried out on him were prompt and appropriate.
Family concerns
99. Following the issue of the draft report, the family’s legal representatives
forwarded my investigator a statement made by a prisoner that had been at
Durham at the same time as the man. The statement concerned an
exchange between the prisoner and the man when he was at Court on 10
March. In the statement, the prisoner described conversations with an
officer and the SO, both based on D wing, about whether he could be
transferred to D wing and shared his anxiety that he did not want him “to
become another statistic”.
100. My investigator spoke to the officer and the SO. Both officers remembered
the prisoner who made the statement for the man’s family. They described
him as getting along well with staff. The officer did not remember speaking
to the prisoner before the man’s death, although he confirmed that he was
working on D wing at that time. He said that he would have understood the
reference to not wanting the man “to become another statistic” to mean that
the prisoner thought the man might be at risk of suicide. The officer could
not recall speaking to the prisoner or the first night centre about a possible
wing transfer or the man’s risk of suicide. The officer said that he would
have spoken to someone on the first night centre where the man was
located and asked whether a transfer would be appropriate, although no
records are kept of such conversations.
101. The SO recalled that he managed D wing in March 2009. He said that he
could not recall speaking to the prisoner about a possible wing transfer or
the man’s risk of suicide. The senior officer also agreed that he would
understand the prisoner’s reference to the man “becoming another statistic”,
as suggestive that the man was at risk of suicide. However, he would have
assured my investigator that he would have acted on such information by
speaking to the wing or to the safer custody team. He said that the man
would have been eligible to transfer to D wing and such a wing transfer could
be arranged, as long as there were no security reasons to prevent it.
102. The investigation team asked the prison to check whether there was any
record of either the SO or the officer speaking to someone on the first night
centre about transferring the man to D wing, or assessing his risk of suicide.
27
There were no records to this effect. Neither officer recalled speaking to the
prisoner who made the statement. Both officers said that they would not
necessarily write down a subsequent conversation because it would be the
responsibility of the wing where the man was located to record such
information in his files. However, both the SO and the officer were certain
that they did not speak to the prisoner about the man’s welfare. With such a
dearth of records, it is not possible to determine whether these two
conversations took place. Following her conversations with the officers in
question, my investigator was satisfied that they understood the appropriate
action to take if such concerns were raised with them. However, it is
surprising that there seemed to be no requirement to record such a
conversation in the record of the prisoner who raised the concerns.
103. Before the investigation was complete, the family raised concerns about the
man’s treatment for depression and the assessment of his risk of self harm.
As discussed above, he was not recently diagnosed with depression and he
was not receiving medication for his mental health. The medication he
received in the community was prescribed at the same low dose, so was a
painkiller, rather than an anti-depressant. Staff told the investigation team
that they considered whether he was at risk. They described the body
language they looked for, and were assured by his manner that he was not
at risk of self harm. I must be careful not apply the benefit of hindsight in my
investigations. Given the information that staff had when they made their
judgement, and his presentation at the time of their assessments, I think they
were reasonable in their judgement that he was not at risk of self harm.
104. The man’s sister told the senior family liaison officer from this office that she
spoke to officers about his depression after attempting to visit him on 8
March. She said she asked them to open a suicide watch. The investigation
team spoke to the officers on duty in the visits area that day. They had no
recollection of that conversation and no record was taken.
105. It is possible that the man’s sister spoke to the volunteers (who are located
at the front doors to direct visitors) although again there is no information
recorded in any logs for that date. The importance of intelligence from a
family member must never be underestimated. His sister was under the
impression that her brother suffered from depression, even though his
medical records demonstrate that he had not recently received treatment for
his condition. Whether or not he suffered from depression, any such
warning from a family member should be recorded. While it is impossible to
determine what exchange took place on 8 March, I make the following
recommendation:
The Governor should remind staff of the procedures in place when a
relative or visitor raises a concern about a prisoner.
106. The man’s sister was not allowed to visit her brother on 8 March because he
had apparently already received two visitors that day. (In fact, the two
prisoners visited two days before his sister’s visit.) The family understood
that prisoners on remand could receive as many visitors as they want to,
28
because they have not yet been sentenced. Prison Service Order (PSO)
4600 – Unconvicted, Unsentenced and Civil Prisoners provides the Prison
Service instruction on what rules should be applied to prisoners on remand.
In this PSO, it requires the following: “He/she can have as many visits and
send as many letters as they wish, subject to practical limitations.” The PSO
is silent as to what it considers to be reasonable “practical limitations”,
although invites the prison to devise a local policy. Despite numerous
requests for the local policy for visits, no such policy was sent to the
investigation team.
107. PSO 4410 – Prisoner Communications – Visits, is more specific about the
number of visits reasonably allowed for remand prisoners, as follows:
“each unconvicted prisoner must be allowed visits on at least three
days a week, including the opportunity for a visit on Saturday or
Sunday, normally every weekend and at least every fortnight”.
It must have been frustrating for the man’s sister to have travelled to the
prison and not been able to visit her brother. It is clear from his records that
he was visited on 6 March and his sister tried to visit him two days later,
Sunday 8 March. I cannot determine whether officers were reasonable to
refuse the visit on the morning of 8 March, because the investigation team
has not seen the local visits policy. I hope that the Governor will satisfy
himself that the visit was refused in line with local policy and, if not, take
steps to prevent this happening in the future.
108. The man’s family were very concerned that news of his death reached their
community before they were notified. The investigation team visited his cell
and confirmed that there were telephones located outside his cell and one
floor above. Prisoners on the telephone when he was found could have
shared that information. The staff priority was to make efforts to resuscitate
him. The (A)SO told the investigation team that prisoners were moved back
into their cells as quickly as possible including those using telephones. It is
regrettable that the man’s family might have heard about his death as a
rumour before being formally notified.
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CONCLUSION
109. The man was only at Durham for just over a week. His reception screening
was not well recorded, but identified that his main problem was alcohol use.
He received an appropriate detoxification, and was well assessed, but there
was nothing available to support him through this physically and mentally
stressful time. It compounds the importance of the missed secondary
healthscreen.
110. He gave staff an incorrect medical history, claiming that he was being
treated for depression. The prison’s failure to retrieve his medical records
meant that this crucial information was not known by staff until after his
death. This might not have had a bearing on the overall outcome in this
case, but would have certainly had an impact on his ongoing care.
111. I am satisfied that neither prisoners nor prison staff noticed any sign that he
was at risk of harming himself or taking his life. My investigation has found
no evidence as to why he might have done so, other than the nature of the
alleged offence, and his alcohol withdrawal. The events of 12 March were
confused, but the clinical reviewer confirmed that he received prompt and
appropriate response efforts from staff. Regrettably, that did not change the
outcome for him and his family.
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RECOMMENDATIONS
1. The Governor and the healthcare manager should that ensure healthcare staff
attend future debrief meetings after a death in custody.
This recommendation was accepted and healthcare staff were reminded of the
importance of attending debrief meetings.
2. NOMS should consider allocation of funding to support the considerable
number of prisoners going through withdrawal from alcohol in prison.
NOMS identified this as a matter for the consideration of the Department of
Health and neither accepted or rejected this recommendation. Although the
report was sent to the Department of Health for consultation, no response has
been received.
3. The Head of Healthcare should remind staff of the importance of following the
clear requirements of the first reception healthscreen.
The Head of Healthcare accepted this recommendation and has already
addressed the matter through formal one to one meetings and the reissuing of
guidance to staff.
4. The Department of Health should consider revising the urine test at reception to
discriminate between heroin and prescription opiates.
As previously stated, the Department of Health has not responded to the
investigation report and there is no indication whether they have accepted or
rejected this recommendation.
5. The Head of Healthcare should devise a system to audit whether prisoners
have received a secondary healthscreen.
The recommendation was accepted. A monthly Primary Care report is already
in place to ensure that prisoners have received a secondary healthscreen.
6. The Governor should remind staff of the procedures in place when a relative or
visitor raises a concern about a prisoner.
The Governor accepted this recommendation and set his response out as
follows:
“Where information is received into the establishment from families, agencies,
and other parties outside the establishment who have a concern for a prisoner
who may be at risk of self-harm or suicide the SPC must record and pass the
information to the area of the prison where the prisoner resides”
The Suicide Prevention Co-ordinator personally interviews the prisoner and, an
immediate needs is undertaken following discussion.
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