Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a man
at HMP Isle of Wight in May 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2010
This is the report of an investigation into the circumstances of the death of a man in
May 2009. He was found hanging in his cell at HMP Isle of Wight (Camp Hill site) at
00.35am, and sadly, he was pronounced dead by paramedics at 00.50am.
The man had transferred from HMP Lewes, where he had been for six months, to
HMP Isle of Wight nine days earlier. This was his first time in custody. He was 24
years old.
I would like to offer this public expression of condolences to the man’s family and
friends on their loss. A key objective of all my investigations is to ensure that the
bereaved family has the opportunity to raise any concerns and contribute to my
inquiries. His parents raised a number of matters with one of my family liaison
officers and my colleague who carried out the investigation on my behalf. I hope my
investigation begins to offer answers to their questions. It is with regret that this
report has been delayed and I offer my sincere apologies for this.
The man spent the majority of his time in custody in HMP Lewes and the
investigation has looked in detail at his time there as well as the nine days he spent
at HMP Isle of Wight. Two separate clinical reviews were carried out and I am
grateful to the Consultant in Public Health, and the Consultant Forensic Psychiatrist
for looking at the clinical care at HMP Isle of Wight and HMP Lewes respectively. I
would also like to thank staff at both HMP Isle of Wight and HMP Lewes for their co-
operation with this investigation.
The man was a vulnerable prisoner with disabilities as a result of a severe life-
threatening asthma attack in October 2005. He had made a serious self-harm injury
within days of arriving at HMP Lewes and had periodically harmed himself again
during his time there. Over time, he appeared to become more comfortable with the
support of staff and, in particular, two prisoners. However, the nature of his transfer,
which I believe occurred without sufficient warning and in a manner which was ill
considered, is of concern. Sadly, he did not appear to settle at HMP Isle of Wight
and died after nine days there.
In what is an upsetting story, the report contains 11 recommendations, many in
relation to HMP Lewes. They concern looking after prisoners who are at risk of
harming themselves, and those with disabilities. I also comment on transferring
information and the importance of completing records correctly.
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 November 2010
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CONTENTS
Summary
The Investigation Process
HMP Lewes
HMP Isle of Wight
Key Findings
Issues
Conclusion
Response to the draft report by the man’s family
Recommendations
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SUMMARY
In October 2005, the man suffered a severe asthma attack which left him with
disabilities. On 7 November 2008, he was arrested and remanded to HMP Lewes on
10 November. He declined to be located into healthcare where staff wanted to
assess his physical capabilities and so was taken to an ordinary wing. In the early
hours of 24 November, he seriously harmed himself by cutting his throat. He was
taken to outside hospital where he remained until that afternoon. Upon his return an
Assessment, Care in Custody and Teamwork (known as ACCT, which identifies,
monitors and supports prisoners considered to be at risk of self harm/suicide) was
opened and he was kept in the healthcare centre for four days.
Over time, the man appeared to settle with some select prisoners helping him with
daily tasks on the wing such as collecting food. On 12 January, another ACCT was
opened after he was found to have burn marks on his stomach. Also, he was
unhappy with his cellmate and threatened to self-harm by cutting his throat. This
was closed four days later without further incident. Again, on 15 February another
ACCT was opened after he cut his neck. The ACCT was closed on 7 March without
further incident although he had been placed on constant watch at court for a short
time on 5 March whilst there to be sentenced. He received a three year sentence.
Throughout his time at Lewes, he had a number of epileptic fits and suffered a
number of injuries following falls as well as having an asthma attack. He always
refused to move onto the healthcare centre preferring instead to stay on the wing.
On 16 April, the man cut his wrist but an ACCT was not opened by staff. A
temporary Medical Record (MR) was opened by the attending nurse as the original
one could not be found. (This record remained in circulation throughout the rest of
his time in custody and travelled with him to HMP Isle of Wight [Camp Hill site].)
The man spent most of his time in a single cell either because of medical reasons or
because he presented a high risk to others. On 30 April, a security report was
logged. It was reported that there were suspicions that his medication was being
taken from him by two prisoners who were recognised to help him on the wing and
provide considerable support. In response, he was supervised whilst taking his
medication. However, on 8 May, he moved into a cell with one of these prisoners.
On the evening of 11 May, the man discovered from another prisoner that he was to
be transferred the following day to HMP Isle of Wight. It appeared that he received
official confirmation of this move early the following morning. According to his
cellmate, he was very distressed about the impending move and said that he would
“just do myself in”. In the morning the cellmate drew the senior officer’s attention to
this and the risk he thought such a move placed him under. However, after speaking
with the duty manager, the senior officer continued with the planned transfer.
Witnessed by a member of the Independent Monitoring Board (IMB, whose role is to
ensure that the prison is properly run and that prisoners are treated decently), who
became involved when the cellmate approached her, he was asked to come out of
his cell under the pretence of speaking with the senior officer. He then tried to return
to his cell which he was instructed not to do.
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As a result, the man was restrained outside his cell before walking cooperatively to
reception from where he was transferred to HMP Isle of Wight. These events were
not recorded on the Prisoner Escort Record (known as the PER which is used to
communicate important information between the various criminal justice agencies)
and an ACCT was not opened.
Upon reception at the Isle of Wight, with incomplete medical records, the man was
seen by a nurse who recognised that he was vulnerable and referred him to the
doctor. However, she did not feel he was at risk from self-harm. He was taken to St
Andrews wing. Two days later, he saw the doctor and the majority of the
consultation was spent discussing his disclosure that he was withdrawing from
drugs. This was the first time he had mentioned that he had been using illicit drugs
at Lewes and there is no collaborative evidence. Again, the doctor felt him to be
vulnerable but not at risk of self-harm.
The man telephoned his family five times over the next few days describing Camp
Hill as a “shit hole”. He seemed to have had little contact with staff or prisoners
except to get a warning for smoking on 20 May.
On 21 May, the man was asked to turn his music down by the night staff at 11.20pm.
At approximately 00.35am, hearing the music had been turned up again, an officer
went to his cell and discovered him hanging. Within minutes, staff entered the cell
but did not carry out cardiopulmonary resuscitation (CPR) as they believed he was
dead. Paramedics arrived at 00.46am and pronounced him dead at 00.50am.
The man had complex needs which were difficult to manage in the prison
environment. Whilst there is considerable evidence that staff supported him at
Lewes, there are 11 recommendations in this report, two specifically in relation to the
ACCT process at Lewes. A number of recommendations are directed at the Head of
Healthcare at Lewes and concern how his physical difficulties were identified and
communicated by staff.
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THE INVESTIGATION PROCESS
1. My colleague collected the documentation relating to the man from HMP Isle
of Wight and opened the investigation in the days following his death. He met
with senior prison managers. Notices were issued to staff and prisoners
telling them of the investigation and offering the opportunity to speak with my
colleagues. No one came forward as a result.
2. The investigator and another colleague visited Camp Hill on 18 June and
interviewed five members of staff and a prisoner. Given that the man spent
six months in Lewes, and was transferred nine days before he died, much of
the investigation focused on his time there. Twelve interviews were
conducted with staff by the investigator between 11 August and 24
September. A prisoner and a member of the IMB wrote to my investigator
and, in addition to the statements they provided, they were also both
interviewed on tape. One other prisoner at Lewes was interviewed. In
addition, my investigator listened to the telephone calls the man had made
from Isle of Wight.
3. My investigator contacted the local Primary Care Trust who agreed to prepare
a clinical review regarding the man’s time at Camp Hill. She conducted two
joint interviews with the clinical reviewer appointed on 18 June. On 17
August, a review panel took place which she attended as well as a number of
staff from the prison and the Primary Care Trust (PCT), and a full report is
annexed to this report. The clinical reviewer did not consider it was
appropriate to comment in detail on the man’s time at Lewes.
4. The NHS and local Primary Care Trust agreed to prepare a clinical review for
the man’s time at Lewes and a second clinical reviewer carried this out on
their behalf. Again, the report is attached. The clinical reviewer obtained the
man’s records from the community and his report contains useful background
information. Both reports are referred to in the Issues section of this report.
5. A family liaison officer from my office made contact with the man’s parents
offering them the opportunity to meet with both herself and the investigator to
discuss the purpose of the investigation and to raise any questions or
concerns they had about the care he received whilst in custody. The
investigator and family liaison officer visited the family home on 15 June.
They specifically questioned:
• The transfer to Camp Hill. They felt that he was settled at Lewes and
would not have taken his life if he had remained there.
• Why he was not considered a suicide risk at the time of his death given his
history?
6. A copy of the draft report was sent to the Prison Service and their responses
to the recommendation are repeated verbatim in the recommendations
section. The response to the draft report by the man’s family can be found on
page 40.
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HMP LEWES
7. HMP Lewes is a small, old category B local prison holding remand and
convicted prisoners and remand young adults, serving courts of East and
West Sussex. It holds 558 prisoners in six units, three of which are residential
wings (A, B and C), and also a first night centre and a small unit for vulnerable
prisoners. In addition, there is a healthcare centre located in a separate
building in the prison grounds. All responsibility for the delivery of the health
service transferred to the primary care trust in 2005. There were three deaths
at Lewes in 2008 and 2009. All were from natural causes.
8. The last announced HM Inspection took place in August 2007. It said:
“Lewes is a small, old local prison …. like many such prisons, the built
environment and facilities are far from ideal: indeed, cells in one wing
were barely fit for habitation and needed urgent refurbishment.
However, relationships between staff and prisoners was extremely
good, within appropriate boundaries. This was the prison’s great
strength. There was evidence that staff knew about, and engaged
with, the prisoners in their care, though this knowledge was not
effectively put to use in resettlement and suicide prevention work.”
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HMP ISLE OF WIGHT
9. On 1 April 2009, Camp Hill merged with Albany and Parkhurst to become
HMP Isle of Wight and is managed as a single unit. Camp Hill was built in the
early years of the 20th century. It is a closed category C training prison
holding adult men on short, medium and long sentences, received from the
local prisons of Winchester, Lewes and the London area. It holds 595
prisoners in nine residential units including St Andrews and St Davids wings
which are, respectively, the first night centre and induction unit. Given its
distance from the mainland, and the expense of travelling there, Camp Hill is
not popular with prisoners.
10. Health services at HMP Isle of Wight are commissioned by the local Primary
Care Trust. The prison’s healthcare is clustered with Albany and is provided
by Parkhurst. Parkhurst provides healthcare to the 1500 or so prisoners on
the island and has a 12 bed in-patient facility (mainly providing psychiatric
treatment). Prisoners’ medical needs are catered for by way of out-patients
and core day primary nursing cover. There is no overnight healthcare facility
at Camp Hill. If an incident should occur during the night, either the nursing
facility at nearby Parkhurst are contacted for advice or the Accident and
Emergency Department at the local hospital. If necessary the prisoner is
taken there or collected by emergency ambulance.
11. Each prison has an Independent Monitoring Board (IMB) made up of
members of the community. The Board’s role is to ensure that the prison is
properly run and that prisoners are treated decently. Each Board produces an
annual report for the Secretary of State.
12. HM Inspector of Prisons conducted an unannounced full follow-up inspection
of Camp Hill from 9 to 13 February 2009. In her report, she wrote that the last
inspection (August 2006) had revealed a prison lacking in direction and was
not fulfilling its role as a training prison. However, the report did note that
under better management:
“… there has been progress in all areas – but despite this the prison
was still not performing sufficiently well in any of our four key areas:
safety, respect, purposeful activity or resettlement. Six of our eight
recommendations from the last inspection had not been achieved, and
the other two achieved only partially.”
13. Camp Hill has had three self-inflicted deaths since 2007, one of these in
February 2009. I have considered whether there are any similarities between
this death and the others. I have found none of significance. To be clear
which part of Isle of Wight prison is under investigation, I will refer to the
prison as Camp Hill in the rest of the report.
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KEY FINDINGS
14. On 7 November, at 11.00pm, the man was arrested for an incident at his
home which involved him self-harming and firing his air pistol from his
window. He was said to have drunk a large amount of alcohol and to have
been disappointed that a new girlfriend did not turn up to see him as
expected. It is recorded that at one point he said that he wanted the police to
shoot him.
15. The following day, whilst still in police custody, the man had a mental health
assessment. The author reported that he always felt low but not suicidal. It
said that he had suffered significant brain injury on top of a background of
previous substantial substance misuse but there was no other evidence of
any other significant major mental illness. His mother was contacted by the
author for background information.
16. The man was taken to Magistrates Court on the morning of 10 November.
The Prisoner Escort Record (PER) indicated that he had risk factors of
“mental condition, violence, concealed weapons and suicide/self-harm”. The
additional information about risk stated “caused cuts to arms/self-harmer,
samurai swords, cross bows and air weapon at H/A [home address]
threatened police with firearm/resisted arrest – 08/11/08”. The form indicated
that he had had a mental health assessment and that the form was attached
to the PER.
17. At 12.30pm, the man was assessed by a court diversion community
psychiatric nurse (CPN) from the Mentally Disordered Offender Assessment
and Diversion Scheme. The CPN opened a Suicide/Self-Harm Warning Form
and assessed the frequency of observations needed to be ‘intermittent’. The
form indicated that reception staff at Lewes prison were aware of his imminent
arrival and that “he denies any current suicidal ideas or plans but has
engaged in behaviour putting himself at risk”.
18. The man was remanded to HMP Lewes. In reception, his core record
recorded his mother as his next of kin and that he had mental health issues.
Section 2 of the Cell Sharing Risk Assessment (known as CSRA and used to
assess the risk a prisoner may pose to themselves and others) stated “mental
health issues, no (sic) very stable, in for fire arms”. He said that he did not
have any concerns about sharing a cell and was not someone who got angry
or frustrated easily. He was assessed as a ‘high’ risk to others indicating that
there was a high level of risk that he might assault his cellmate. The same
officer wrote in the history sheet
“high risk for mental health grounds. In for fire arms offences (shooting
at police). Some very strange answers and questions on the FNC [first
night centre] interview, trying to get him to the health care for obs
[observations], came in with sack of medication. High risk agreed by
the Governor”.
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19. Section 4 of the CSRA was completed by the Governor and he wrote ”in
reach referral” and “to be reviewed by in reach staff in 7 days”. The First
Night Centre Interview recorded the man as “cutting his arms at home on
6/11/08”, but not feeling like self-harming now, had been treated for
depression and he was NFA (no fixed address). The question about whether
an ACCT was opened is not ticked as either yes or no.
20. Section 3 of the CSRA should be completed by a healthcare member of staff
and usually by the same person who completes the First Reception Health
Screen (FRHS). In the man’s case, this did not happen. In response to being
asked about the risk to others, the author has ticked that there was
“insufficient evidence to give an opinion” and assessed him as a low risk. The
author is also asked to assess whether there are any concerns about self
harm and this has been ticked as no, although they recorded “history of self-
harm with recent self-harm (07/11/08). To be referred to in reach”.
21. A First Reception Health Screen (FRHS) was completed and the man gave
details of his recent self harm. He said he usually drank heavily twice a week
and was receiving medication for mental health problems. He said he did not
feel like harming himself at that time. The author indicated that a referral to
the doctor for physical health and substance use would be made as well as a
referral to the mental health in reach team.
22. Corresponding notes were made in the Medical Record (MR). It was also
recorded that the man “would not come to healthcare when offered so that we
could assess his physical capabilities and how he would cope on the wing”.
He was located in an ordinary cell, K1-017 on his own, on the first night
centre.
23. Although, there are numerous recordings of his recent self-harm, the man
does not appear to have presented as at risk and there is no mention by staff
of the suicide/self harm form completed by the CPN at court. An ACCT was
not opened.
24. The following day, the man saw the doctor (GP). Although it is very difficult to
decipher the writing, the GP concluded that “I think he will cope on ordinary
location”. A full medical history was not taken. His prescription charts were
not given to my investigator and it is not entirely clear whether or not the man
was prescribed the same medications he had in the community.
25. The man later saw Nurse A from the in reach mental health team. In
interview, the nurse said that his physical problems made him appear as if he
had a learning disability, which he did not, and the nurse was concerned that
he would not cope on the wing. The nurse made an entry in both the history
sheet and medical record. In the history sheet, he wrote “seen by mental
health triage, no concerns re. mental state, however I have agreed to see him
in 2 days time to see if he is coping on the wing (re. physical issues)”. In the
medical record, he recorded
10
“Seen for mental health triage, no evidence of mental illness. No
thoughts of suicide or self-harm. Stated self-harmed a few days ago
out of frustration. His issues are as a result of his physical problems
which may cause him to be exploited on the wing, however he feels
confident to be located on the wing”.
26. A Cell Sharing Risk Review (CSRR) was carried out the same day and he
was assessed as a high risk of harming a cellmate. (Only one page of the two
page document was given to my investigator.) He was moved to cell G1-013,
again alone in the cell, on the induction wing.
27. On 12 November, the man was found in a collapsed state having suffered a
fit. He had not lost consciousness and was assessed by a nurse. He was
referred to see the GP the following day. Again the entry is difficult to read
but it seems that there had been some gap in medication which was restarted.
The GP concluded that he is “settling down in prison fine”.
28. Nurse A saw the man on 14 November and wrote ‘”coping well no problems
or concerns. No evidence of any mental health associated problems. No
further action at this time”. On 18 November, he moved to cell C2-016 and
the next day a further CSRR again assessed him a high risk (page two was
missing again from the documents provided to my investigator).
29. At approximately 3.30am on 24 November, the man made a deep cut to the
left side of his neck with a razor. Having pressed his cell bell, he was taken to
outside hospital where he remained until the afternoon. He was placed in the
healthcare centre upon his return in a dormitory with four others as he
requested company. An ACCT was opened which recorded that he said that
he did not want to die but wished to release his frustrations. On 25
November, he was visited by his mother which was said to lift his spirits.
However, during the ACCT assessment interview later that day, he said that
he did want to be dead and was disappointed that he was not. He had
benefited from his mother’s visit.
30. A Risk Screening Assessment was completed by a member of the in reach
team on 24 November. In relation to his mental health it is recorded:
“No evidence of mental illness. Says he has cut himself in the past to
relieve anger/frustrations/stress caused by the physical disabilities and
particularly being unable to be a ‘proper father’ to his 2 girls’. Says he
has no wish to die, however when he cut his neck on 24/11/08 he felt
he would be better off dead rather than being a ‘partial dad’ although
he says that it was an impulsive action and on reflection a silly thing to
do. No wish to dies or self-harm at present.”
31. It was also recorded that it was his first time in prison and “despite disabilities
feels he will cope and not be subject to bullying. Feels he can “stick up’ for
himself’”.
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32. The man remained in healthcare for four days and was generally settled. He
returned to C wing on 28 December and was placed in cell C4-003 on his
own. In his medical record, it is recorded that “nurse from the mental health in
reach team has seen the man and agreed to take him on his case load”.
33. Two prisoners became aware of the man after this incident as they were wing
cleaners and had cleaned up the cell after he was taken to hospital.
According to them, and from accounts from staff, he began to spend a lot of
time with them both. They generally looked after him on the wing, helping him
get his food and other personal tasks and protecting him from any negative
comments from others. (Prisoner A wrote an account of events from his
perspective.)
34. Prisoner A, who was also a peer supporter (prisoners who volunteer to
support other prisoners and are selected by staff) said in interview that they
became very good friends. He said that the man needed people to approach
him rather than vice versa.
35. On 1 December, concerns were expressed by staff that the man was losing
his balance and falling over. He was seen by healthcare staff and it was
recorded that “referred by staff to be manifesting strange behaviour”. The
same day, Nurse A wrote
“seen for follow up after being discharged from healthcare, he is settled
on C wing. However, he is requesting to be moved to the 2s [second
floor] landing due to mobility issues. On presentation, I did not feel he
was expressing any suicidal ideation or intent and he denied any
thoughts of self harm. He gave me a verbal agreement that he would
ask for help if he felt he may self-harm. In-reach will support for the
short term”.
36. The man fell on 2 December and was seen by the doctor. It is recorded in the
medical record that he was now “flat located [on the ground floor] which
should make things easier for him regarding mobility” and he moved into a
different cell. An entry in his history sheet, says that “advised via healthcare
that he has asked to share a cell. The doctor has taken him off medical single
but obviously care must be taken when allocating a cell mate”. Nurse A wrote
in his medical record on 3 December that “requesting to have his medical
single status removed as he was lonely. Dr removed the single cell status.
From my point of view I said that sharing a cell may provide him with a sense
of friendship”. He moved into cell C2-001.
37. On 3 December, Nurse A completed a care plan. He wrote that “in reach will
provide the man with weekly support on the wing in order to build a rapport
and gain a wider view of the social pressures he is under”. The next day, a
cell mate moved in with him, and continued to share with him for a month.
38. Two days later, on 5 December, the ACCT was closed with a post closure
review booked for 12 December. At the review, the man said that he was
12
settled on the wing and had no thoughts of suicide or self-harm. He also said
he was getting on well with his cell mate.
39. It is recorded in his medical record that the man collapsed again on 10
December. He was assessed by healthcare and advised to contact staff if he
felt unwell again. On 12 December, Nurse A saw him and recorded that he
was “coping well, glad to be sharing a cell ... no worries/concerns raised”.
Another Risk Screening Assessment was completed and the management
plan concluded:
“No current mental illness and no suicidal ideation.
His problems are primarily to do with poor physical health and inability
to deal with stress and failure to get his perceived needs met – has
declined admission to HCC [Healthcare Centre].
Very low key Inreach involvement.”
40. On 13 December, a Report of Injury to Prisoner form was completed
indicating that “whilst escorting the man to reception to collect his property he
became unstable and fell forward to the floor. He appeared to have grazed
both hands”. This incident is not recorded in any other document including
the medical record. An entry in his medical record on 15 December recorded
that he did not feel he needed any additional services.
41. On 16 December, the man fell down the stairs and was assessed by medical
staff. They concluded that he had no ill effects or injuries. There is a mention
that he had taken four Clonazepam tablets rather than two that morning.
(Prescription charts from a later period show that he was being given four
Clonazepam daily which may have been meant to be taken in two separate
doses.) Four days later, he had an asthma attack and the emergency
healthcare nurse attended. The nurse stayed with him for over an hour until
the symptoms passed. Again, he declined admittance to the healthcare
centre for observations.
42. Officer A wrote in his history sheet on 25 December “still unsteady on his
feet, has moments when he just stares into space, HCC (healthcare centre)
are aware, I feel he would be better suited to HCC than normal location and
have said as much to HCC”. In interview, she said that she had chosen for
him to be in the cell opposite the servery to reduce the amount of walking he
had to do. She described other prisoners as looking after him in a protective
way and helping him with tasks.
43. Nurse A saw him on December 29 and recorded:
“Seen on the wing, appears bright in mood and no problems or
concerns raised. He and I spoke about discharge from the in reach
caseload, he was happy to be discharged however I felt that maybe he
should be jointly assessed by another member of the team as he was
expressing vague suicidal ideation, I was unable to gain any evidence
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of any active intent on examination. I will see him with another member
of the nursing team before discontinuing any care plans.”
44. The next day, Nurse A tried to see the man with a colleague but he refused as
he was watching television and did not want to miss a particular programme.
45. On 3 January 2009, the man’s cell mate changed. Later, he rang the cell bell
as his new cell mate was hearing voices and sitting in corner shaking. The
cell mate was taken to the healthcare centre and did not return to the cell.
46. An entry in his history sheet on 6 January says that “the man seems to have
settled down recently. He is still unsteady on his feet. He is genuinely polite
to staff and follows wing regime. Staff still keep an eye on him but we are less
concerned with him of late”. Later that day, he had a fit. He had slept through
the collection of medication earlier in the day and wing staff were asked to
monitor him and wake him overnight for his medication.
47. On 8 January, a new cell mate started to share with the man. An incident
occurred on 12 January at 1.15pm and the following was recorded in his
medical record by Nurse B:
“Seen in response to an urgent request by officers on C wing. The
man had refused to his cell (shared) as he was demanding a single cell
and threatening to cut his throat if his demands not met. Situation
gradually diffused and he agrees to return to cell, (unable to decipher
writing) whilst situation further discussed and resolved. As he has
complex physical health problems due to acquired brain injury he was
offered a bed in HCC to monitor his physical health and maintain
personal safety – poor balance, epilepsy etc; he adamantly refused to
come to HCC stated his needs were not severe enough – see report on
file by doctor re his ability to make decisions re his care. Assessed as
high risk by officers and needing single cell. Discussed my
reservations re his physical health safety in a single cell with a
colleague and we agreed that there were no grounds to forcibly move
him to HCC + he has capacity to make decisions re his care ie. Not
being admitted to HCC despite being advised to. He is not currently
mentally ill and is not expressing any suicidal ideation or intent. His
problems are connected with his physical illnesses and poor coping
skills linked with anger + frustration when he does not get his perceived
needs met. In reach will continue low key monitoring.”
48. Another CSRR was carried out and again the man was assessed as being a
high risk to others. Further details (which had been missing from previous
documentation) recorded that he had threatened to set a fire in his cell. The
form recorded that “he is of low intelligence and has trouble interacting with
others. He has had previous issues with other cell mates”. It concluded that
he should be in a single cell. Due to his fits and asthma, he was to be
monitored and his cell bell should be answered as soon as possible due to his
medical history. The duty governor commented that there should be a further
review in a week to see if a suitable cell mate could be found.
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49. At 3.30pm, one of his personal officers opened an ACCT as he had burn
marks on his stomach made with a lighter. In interview, she recalled him
saying that he had burnt himself because he was bored. She explained that
she would have to open an ACCT and he told her that she did not need to as
he was not going “to do anything stupid” (meaning harm himself again).
50. Officer B carried out the ACCT assessment interview on 13 January. He
recorded that the man would not talk about the burn marks but had told him
that he had done them a few nights earlier. The ACCT was closed on 16
January after no further incidents or concerns about self-harm. At this review,
it was recorded that “the man categorically states that he has no intentions of
self harming or suicide. He now has a single cell and accepts that he will be
sentenced soon and then would like to go to HMP Camp Hill which is where
his brother is. Document closed”. (The man’s mother told my investigator this
was not the case. His brother had previously been at Camp Hill but had
transferred to another prison some weeks before.) A review was carried out
on 23 January.
51. On 17 January, the man fell in his cell and medical staff attended to treat his
hand, which was swollen. His history sheet records that on 19 January “the
man has spent the last couple of days in bed, since he had a fall on Saturday.
He was seen by healthcare. He remains polite to staff, does have to be
chased up to go behind his door”. On 25 January, healthcare said that it was
unsafe for him to use the stairs and so he needed to exercise in the
healthcare centre yard if the lift was broken.
52. The man spoke with his personal officer again on 3 February (they were
meeting bi weekly). She described his mood as being “very up and down of
late”. An entry in his medical record on 4 February, indicated that he had not
requested any support from the in reach team for a while and consequently he
was discharged from their caseload.
53. On 5 February, the man appeared at Crown Court and pleaded guilty to the
charges. A Pre-Sentence Report was requested for the next hearing in a
month’s time. Another CSRR was completed and again it was recorded that
he ‘has threatened cell mate and attempted to set fire to them’. The author
wrote that the man “does talk to me but sometimes it’s difficult to know if he
understands what is being said”. It concluded that he was to remain on his
own as “there is a perceived risk to cell mate”. Also, the form said he suffered
from asthma and panic attacks (this is the one and only entry in all the
documents about panic attacks).
54. The man cut his neck again with a razor blade on 15 February and an ACCT
was opened. The injury was skin deep and he would only let healthcare cover
it with a dressing. He wanted to speak with his friend, Prisoner B, who
persuaded him to have some sutures put in. He was placed in a cell
overnight with the prisoner “to keep an eye on him”. During his ACCT
assessment interview, he said that boredom was his main problem and that
he did not want to kill himself. He was described as a “serial self-harmer”.
15
Staff were going to try and give him work whenever possible. A referral for a
psychiatrist’s assessment was competed that day so that he could discuss his
anti-depressants which he said were not helping him.
55. In interview, Prisoner B remembered this incident. He said that the man was
worried that if he went over to the healthcare centre for treatment he would be
kept there. The prisoner said that he did not want to go because he was a
smoker and smoking is not allowed in healthcare. Having gained
reassurances from staff that he would come back to the wing, the prisoner
managed to persuade him to go and have some treatment. He was then
allowed to stay overnight in the prisoner’s cell.
56. On 16 February, the Disability Liaison Officer conducted a Disabled Prisoner
Care Plan. The purpose of the assessment was to consider whether any
“reasonable adjustments” were needed to accommodate the man in his every
day life. His ‘disability’ was described as “he has got brain damage due to
lack of oxygen. He is a bit slow but has no memory loss. He has a tendency
to self harm”. It concluded that he needed no assistance in any areas.
57. Officer C had a routine meeting with the man on 16 February. He told the
officer that he gets bored and would like a wing job and she wrote that staff
would look into the matter and see what they can do. She also recorded that
he was very close to Prisoners A and B who “tend to be able to keep his
spirits up.” In interview, my investigator asked if he appeared depressed:
“No, not very often; most of the time he was happy. Sometimes he’d
spend a couple of days in bed and then you’d go in there and sort of
will him to get up because obviously he was having bad days and I
think it was times around his birthday or his children’s birthdays he’d
mentioned that he was feeling quite low. So obviously I mean the staff
got on really well with him on C wing, we got to know him quite well.
So if we couldn’t wheel him out of bed then we’d obviously speak to the
two prisoners because they used to go up there and go and have
words with him, see if they could get him up.”
58. A referral to the mental health in reach team was completed on 16 February
as the man made a superficial injury to his neck the day before.
59. An ACCT review took place on 22 February at 2.30pm. The case manager
was a senior officer from another wing who had not met the man before and
was involved solely because he was the duty manager that day. In the
review, he described finding the support of Listeners helpful (there is no
record of him requesting Listeners in his on-going record although he was
spending time with Prisoner A who was a peer listener) and had good eye
contact and interaction throughout. (Listeners are prisoners trained by the
Samaritans and are available at all times for prisoners to speak with.) Again,
they spoke about getting work and him being bored. There is a record in his
on-going ACCT document at 11.20am on 23 February of him saying that he
told his solicitor that “if he gets a custodial sentence, he will kill himself”.
16
60. Another ACCT review took place on 1 March, again with two discipline staff,
but the man refused to take part. It was reported that he had spoken to his
personal officer, Officer C, and that he had “no intention of self-harming”. SO
A, who was acting as the case manager, spoke to him in his cell and he said
he was “feeling ok” and reiterated what he had told Officer C. He said he was
looking forward to going to court later in the week.
61. On 2 March, Officer D wrote in his history record: “The man is still quite shaky
physically and has had his stitches in his neck removed. He does not engage
in conversation with me but spends a lot of time with Prisoners A and B who
look after him”.
62. The man appeared at Crown Court on 5 March 2009, to be sentenced for the
offences of possession of a firearm/imitation firearm with intent to cause fear
of violence and possession of a bladed article. The Pre-Sentence Report
(prepared between 5 February and his court date) said “The man informed me
that should he receive a custodial sentence he would kill himself. He also
expressed that he was unable to cope with the daily battle of life anymore”. At
12.15pm, whilst at court, he was placed on a constant watch as he was very
distressed following a visit by his solicitor. At 12.50pm, he had a closed visit
with his parents and appeared more settled and was taken off constant watch
at 2.00pm. He then appeared in court and was sentenced to three years
imprisonment. Upon his return to Lewes, he was again placed on constant
watch for an hour and 40 minutes. He then told staff that he was fine and had
no thoughts of self-harm. He declined to see a member of healthcare and
was taken off constant watch.
63. On 7 March, at an ACCT review, again with two discipline staff and those who
carried out the first review, the man said he was in full time education. He
also said he “has been sentenced now and is happy with the result as he only
has a year to do”. He spoke of his family support and the drawings he
received from his children. The ACCT was closed. At the post closure review
on 14 March, he said he was well.
64. An entry in the wing observation book the same day says that the man rang
his cell bell, saying he thought he was going to have a fit soon. Healthcare
staff were contacted but wing staff apparently were told that they would not
intervene with any one having a fit. He was to be advised to lay on his bed.
65. The man had a regular meeting with Officer C on 16 March and said he had
been quite happy during the past week. He was attending education and
mixing with a few other prisoners on the wing. The next day , 17 March, he
tripped and fell when leaving the servery. On 30 March, it is recorded in his
history sheet that he remained polite to staff and was still attending education.
There were no concerns about him.
66. On 31 March, another CSRR was carried out and the same information
repeated about previous threats to cell mate. The author concluded that
‘”given his unpredictable nature I feel it would be wise to move him to medium
risk. Should he find a suitable cell mate who he wished to share with then his
17
CSRA can be reviewed. However due to his previous history, the risk should
be fully explored”.
67. At his bi-weekly meeting with Officer C on 13 April she said that there was no
change but she believed he used his illness as an excuse to do as he
pleased. In interview, she explained that he could be quite cheeky and child-
like. She spoke about how settled he appeared at Lewes.
“I can remember coming in the day after he’d done it (self-harmed on
24 November) and that was the first time I met him or a couple of days
after he’d done it and that’s the first time I’d ever met him. And from
the first time I met him up until when I went onto nights he was
completely different person. He’d sort of settled right into the wing, he
knew the staff extremely well, he knew that he could talk to us about
anything and he also liked, say came really good friends with Prisoners
A and B. And I think he was quite settled and he could accept his
prison sentence being in an area he felt comfortable. So I should say
from when he first came he was feeling very low and withdrawn and
probably at more risk than he had been the whole time he was at
Lewes.”
68. An entry in the wing observation book on 13 April at 5.50pm, says that “staff
to monitor closely has previously self harmed by cutting throat. Advised by
Prisoner A that the man is down in the dumps and should be watched by
staff”. Another entry at 6.30pm, says “Prisoner A put in cell C2-01 to speak to
him. Concerns raised as he may self-harm. Agreed by Oscar 1 [duty
manager]. Prisoner A returned to own cell at 7.20pm stating the man ok.”
69. On 16 April an entry in observation book says “rang bell. He sat on bed, had
made slight cut across L wrist, N/O [night orderly officer who is the most
senior member of staff at night] and H/C [healthcare] informed and attended.
No ACCT opened”. At 8.25pm, Nurse C recorded in the medical record
“called to C wing, he had cut his left wrist small clean cut cleaned and
dressed. Razor blade removed from cell. To see GP tomorrow for
assessment ? taking medication”. There is also a note saying “can’t find IMR”
and the front of the medical record it is written “original IMR not found –
temporary file”. (This file became his on-going medical record.)
70. In interview, Nurse C recalled dressing and cleaning the wound and said that
the man spoke about his family and that he harmed himself to relieve stress.
When asked about opening an ACCT, she said;
“We can, yes. I didn’t feel at the time that it was, because so many of
them just do it for stress related, we don’t open one for everyone. The
officers, if they, felt needed one they could have opened one as well, I
don’t remember any discussion about it actually, that night. And in fact,
yes I suppose in retrospect, but even the following day the doctor didn’t
feel the necessity, after he spoken to him.”
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71. Nurse C remembered the man from February when she had attended after he
cut his neck and she had referred him to the in reach team. She felt the
previous self-harm had been more severe and that the discussion with him felt
very different from before.
72. SO A was the night orderly officer (duty manager) that night but in interview
could only recall the incident vaguely. Asked about why an ACCT was not
opened he said:
“Well, everybody is trained to a certain level within the establishment. I
would assume that the OSG (night staff) who found him with an injury
would have instigated opening an ACCT, if not healthcare since they
go back and write the reports for the doctor the following day. They
would have opened an ACCT because they are privy to far more
information than our uniformed staff are and individuals.”
73. He also did not recall having a discussion with staff about opening an ACCT.
74. There is a further entry which is unsigned and not dated which may have
been written that day which reads “feeling quite low - not a suicide attempt …
refer to in reach”. In interview, Nurse C said this was written by the doctor the
following day.
75. It is noted in the medical record on 17 April that a fellow prisoner reported that
the man had fallen down stairs and had a bump on his head and elbow. Four
days later, in reach staff attempted to see him but he was at education. On
19 April, it is recorded that he asked for and saw a Listener.
76. On 30 April, a prisoner passed a note to Officer D saying that “Prisoners A
and B were taking four Clonazepam off the man every morning”. In interview,
she said that she completed a security report and instructed that he was to be
supervised by healthcare when taking his medication. This is recorded in his
medical record as “phone call from wing – he’s being bullied for his
medication. Clonazepam to be supervised at hatch and taken over in
evening”.
77. In interview, Prisoner A said that he was aware that people had suggested
that he was involved in taking medication from the man. He denied this. He
said that he knew what medication the man was prescribed. He and Prisoner
B would tell him to take it on a couple of occasions they had seen piles of pills
in his cell which he had not taken.
78. On 3 May, an entry in the man’s history sheet said “needs chasing from time
to time and relies heavily on Prisoners A and B – these two look out for and
after him on the wing. Has his ups and downs and seems to be ‘up’ at the
moment, needs to be monitored easily falls into self-harm”. The next day,
there is an entry in the wing observation book which said that he was
distressed about something another prisoner had said to him but he would not
repeat what it was. He asked to see the in reach team and a message was
left for them.
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79. Two days later, an entry in the medical record recorded “form from gym re
fitness for gym. Is epileptic and asthmatic – severe. GP appt given for
Monday 11 May 09. Dr to assess fitness for gym”. On 7 May, an entry by
Nurse B, from the in reach team, said “seen flowing a referral….no indication
of any severe/enduring mental illness – appeared to have mild LD [learning
difficulties] and some reactive depression – he’s worried about future, does
not like prison and feels lonely. No current suicidal ideation or intent …
regularly attends gym and education – he feels that he is ‘okay’ at present and
does not need any help. No further action.”
80. The man’s MR says he is “fit for transfer” on 8 May as recorded by Nurse D.
In interview, she explained this as a simple paper process which involves
checking whether the prisoner has any outstanding hospital appointments or
any other medical reason for holding them at Lewes. It does not involve
interviewing the prisoner and is usually carried as one of the night duty
activities.
81. The man started to share his cell with Prisoner A on 8 May. In interview, the
prisoner said that they began sharing because both of them were in single
cells and it was likely that he would be moved from his. He says he
suggested to him that they share and staff agreed.
12 May
82. Given that the man was a sentenced category C prisoner, he was eligible for
transfer. According to Prisoner A, who was sharing a cell with him, he
became aware that he was being transferred the night before when another
prisoner came into the cell to say that he had seen his name on the transfer
list in the wing office. The prisoner said that the man had not received a
notification slip which they usually get with at least 24 hours notice. He said
that his face dropped when he heard the news and so he told him he would
speak to staff. The prisoner approached the office but was told that it would
be something to be looked at in the morning because it was about 6.30pm
and the day staff were not there.
83. Prisoner A said that the man was very distressed during the night and said
that “I’ll just do myself in”. He said that he tried to reassure him that he would
see the senior officers in the morning and that he would be able to sort it out.
In interview, he said that because of the man’s history of self-harm they were
sure they would stop the move. Early that morning, he says a slip was put
under the door about the transfer. He says that as soon as they were
unlocked he went to the office and spoke to SO A who said “I know what you
are going to say and there is nothing I can do”.
84. SO A recalled Prisoner A coming to see him and showing concern regarding
the man. In interview he said:
“I have been trying to remember, he was concerned, he felt that it
wasn’t good for him to go there because you know people here were
looking after him, he would be on his own down there. It would
20
probably put him back two steps from how much he’s advanced since
he’d been at Lewes, because yes he did quite well here, I know he self
harmed a couple of times but he was out and about, he was cleaning,
he seemed a little bit better and so he came to speak for him. Because
Prisoner A’s been in a long time, he knows the system better than most
people and he’s had a couple of good responsible jobs on the wing.”
85. The SO was unable to recall whether or not he spoke directly to the man at
this point about what he thought about the transfer. In terms of what exactly
Prisoner A said about his worries about the man in relation to the risk of self-
harm/suicide, SO A said:
“I wish I could sit here and say I remember clearly what was said in that
office, I don’t recall those words but then again if he had those
concerns I’m sure he would have said it. I’m not saying he didn’t say it,
it’s just I can’t sit here and honestly say to you hand on heart I
remember him saying to me he’s going to do this or that or the other,
but if he had those concerns I’m sure he would have said it, I’m no
doubt he would have said it if he had those concerns.”
86. Prisoner A said that SO A said he needed to hear from the man himself and
according to him the man did tell the SO. The prisoner described him as
becoming bashful and in quite a state with a stutter and twitch which he said
got worse the more stressed he became. He said that he asked for in reach
to be called to come over and assess the man. SO A could not recall if the
man was with Prisoner A in the office.
87. SO A said that he contacted the duty manager (Oscar One) to get advice
about what to do in the circumstances. He was unable to recall exactly what
was said “I don’t recall exactly what I said but any concerns that I would have
had about potential of, any sort of self-harm I would have passed onto Oscar
One”. My investigator asked if he considered opening an ACCT:
“Well no he was going to be transferred that morning, the concerns that
I had passed to Oscar and then Oscar 1 deals with him how they deal
with it within their control. He had already been cleared by healthcare
to be transferred so, like I said before, I play a very small part in the
whole process of being transferred. Nine times out of 10, if not more, I
don’t even get involved.”
88. Prisoner A in interview said that later he was on the telephone and saw
someone form the Independent Monitoring Board (IMB). A member of the
IMB was on the wing at the time with a colleague who was being inducted. In
interview, she said the prisoner approached her and told her that the man had
had a note slipped under his door that morning about being transferred to
Camp Hill and that he was very agitated.
89. She went into the cell to see him, who was lying on the lower bunk bed and,
having knelt down, she introduced herself and asked him some questions.
She said that he did not respond and was “just lying there not looking at me at
all, not looking at anyone, just lying there”. The prisoner told her that the man
21
was a self-harmer who had attempted suicide before and that as long they
were together, he would not attempt suicide.
90. She felt that she needed to find out more information about the situation and
why the man had not been given more notice about the transfer. She
approached Officer A in the office, which was a very short distance from the
man’s cell. She said that Officer A told her that it was a good thing that he
was being moved because there was a suspicion that Prisoner A was taking
his drugs. Officer A confirmed this in interview with my investigator. She said
that the move to Camp Hill would be in his best interest so that he could get
his medication. There is no evidence to support that healthcare had been
contributed about his move. At this point, they were interrupted by a
“kerfuffle” behind them and the IMB member looked round to see the man
being taken to the ground by officers. She retreated at this point to observe
what was happening. She said she heard Officer A telephone healthcare to
ask for two nurses come to reception urgently.
91. In interview, Officer A said that she thought the decision had been made not
to tell the man too far ahead about the move. SO A said that staff were
watching the relationship between the man and Prisoners A and B carefully
but there was no proof that bullying for his medication was taking place. He
thought that they looked after him, taking him food and generally helping him
out. He felt that the suspicion about bullying would not have been the reason
for the transfer which would have been routine. If bullying had been the case
there would have been a number of options that they could have taken place
such as moving him to another wing or, (as is policy) moving the perpetrators.
He said that some staff were surprised that he was being moved but was
unable to expand on this. He could not recall any discussion about staff
agreeing not to tell him in advance of the transfer.
92. SO A said that he wanted the man to be transferred with the least amount of
trouble. In interview, he said
“…. I knew he had to go so I had to try and think of a way of trying to
get him in to the office so I could talk to him and say look you’re going
and that’s it, so I asked staff to ask him to come and see me under the
pretence that he was just going to come and talk to me. I didn’t want it
to get heated and turning into an argument or potentially you know
even worse, and sort of like Prisoner B getting involved and the man
getting you know sort of upset like about everything, I wanted to keep it
calm and low key, so that’s why I wanted to separate them.”
93. The SO asked Officer E to take the man out of the cell by saying the SO
wanted to see him in his office. In interview, the officer described knowing the
man quite well as a very polite individual who did not mix with many people.
He said staff took “quite a caring role with him, sort of looked after him”
probably because he “was that little bit more vulnerable”. The officer said he
“seemed to become very, very settled in the end; he was very comfortable on
the wing”.
22
94. Officer E said that, having got the man out of the cell, he then attempted to go
back to the cell and was told he could not. He was shouting through the door
to Prisoner A about what was happening. The officer said that, despite being
asked to come away from the door, he ignored the instructions of the staff.
He was heard to say that he wanted to say goodbye to Prisoner A. Three
officers were then involved in restraining him. Officer E was asked about the
decision to restrain him. He said:
“Yes, I wouldn’t say restrain him. Basically Officer F pulled him away
from the door to which then he started to get quite agitated. Myself and
Officer G then took one arm each, then he went down onto the floor.
We didn’t take him down to the floor, he went down to the floor of his
own accord.
We just literally held them [his arms]. He then struggled and sort of
lowered himself down to the floor, at which point we attempted to put
him into an arm lock for control.”
95. Officer E explained that the arm lock position which the man was placed in
was an alternative to his arms failing about and instead they were put in to the
back hammer position. However, he explained;
“.. as we attempted to do this he said ‘ow, ow, my arms don’t bend that
way’. At that point all locks were completely released and he was
helped to his feet and subsequently he was walked down to the section
under no formal restraint whatsoever and he walked willingly down to
reception. The whole incident was witnessed by the IMB as well.”
96. The IMB member followed them to reception. Officer E and G said that the
man was crying as they walked but he could not recall any conversation. In
reception, the IMB member asked the healthcare staff if he had taken his
medication and they told her he had. Nurse D was one of two nurses who
attended reception and she recalled asking him if he was okay to which he
answered he was fine. The IMB member approached him and, after
introducing herself again, asked if he had any concerns about being
transferred. She said he did not answer her. She remained for a short while
and then left reception.
97. The IMB member wrote to Prisoner A later that day which read “The man was
taken to reception this morning and was supervised by HCC. He was calm,
after an initial struggle. He was compliant about being moved to Camp Hill
and will be medically supervised when he gets there.”
98. Officer E returned to the cell and Prisoner A packed up the man’s
possessions. The officer then returned to reception where the transport was
waiting to take the prisoners. Officer F, who had been involved in the
restraint, processed the possessions through reception. He said that by the
time the man got onto the van he seemed fine.
99. Prisoner A commented that he had heard that the man was only transferred
because another prisoner had managed to avoid going and the man went in
23
his place. My investigator could find no evidence to support this having
examined the list of transfers.
Camp Hill
100. The risk categories for violence, conceals weapons and suicide/self-harm
were ticked on the PER which accompanied him to Camp Hill had. Under the
section of further information about risk is written ”closed ACCT. Threatened
police with firearms/resist arrest 08-11-08. Conceals weapons – samurai
swords, cross bows and air weapons at H/A”. Under the section about
medical risks, the form indicates that there are no known risks. Also, there
was no mention of the control and restraint used at Lewes immediately prior
to the transfer.
101. The man arrived at Camp Hill at 2.28pm. Staff Nurse E conducted the
medical screening when he arrived. The medical records which travelled with
him were incomplete because the original had been lost and a temporary file
had been generated. In essence these were the medical records from 16
April to 8 May.
102. The nurse, in interview, said she spent about 30 minutes with him. He told
her of a history of drug misuse and that, prior to coming to prison, he drank
eight cans and a bottle of spirits daily. She said “he presented as quite
anxious. He had a lot of trouble with his speech, he would start to talk to me
and then he would actually stop and then restart again and then going through
his medical history I discovered why he was like that”. She asked him directly
about whether he thought about harming himself and he said that he was not.
She referred him to the doctor for a medical review.
103. The nurse decided that he should have a single cell for medical reasons
because he said that he was up quite a lot during the night and disturbed
people. She assessed him as medium risk because of the previous self-harm
and thought that it needed to be reviewed. He was located on the ground
floor due to his mobility difficulties.
104. The medical notes received at Camp Hill were incomplete although the prison
did receive the man’s self harm history. Nurse E arranged for a GP
consultation with the prison doctor due to the nature of his conditions.
105. Following the meeting, Nurse E discussed the man with a member of the
Mental Health In Reach Team (MHIRT). They agreed that a routine referral
was appropriate (which was outstanding when the man died. It is usual for a
referral to take a few weeks to be processed).
106. That evening, Prisoner A said that he wrote to the man trying to reassure him.
He still had a “few bits of his belongings as he had only two minutes to pack it
all up, and to keep his chin up”.
107. On Friday 15 May, the prison doctor assessed the man. He was not the usual
doctor at Camp Hill but she does drug misuse work there. Her colleague was
24
away and she agreed to see him because Nurse E told her that he had a
complex medical history. The nurse did not want to wait until after the
weekend for him to see the doctor. She said that Nurse E was “not
concerned about his immediate safety but she was worried about him, she felt
he was quite vulnerable in the prison, that he had a lot of complex problems
and felt that we ought to be aware of him sooner rather than later”.
108. The doctor said that she spent about 25 minutes with him and the first part of
the consultation was spent talking about his drug use. He said he had been
using heroin and snorting Subutex until the point of transfer and had last used
three days before. His withdrawal appeared to be largely over by the time of
their consultation but she did prescribe symptomatic relief for the symptoms
although he did not collect this medication. He said he was “comfortable”.
After the consultation, she referred him to the Substance Misuse Nurse Lead.
109. In interview, the doctor described an in-depth discussion with the man about
his drug use and the problems he had since the severe asthma attack. She
has a special interest in mental health and said “I very much hoped I would
have picked up (depression) at that point. I mean you can never be 100%
sure about people, but he was communicating, he maintained eye contact, he
was happy to answer questions, I felt that he had engaged with me”. She
described there being “an air of sadness” about him. She said it did not occur
to her to open the ACCT procedures. She said that the subject of his drugs
withdrawal dominated the consultation and they did not explore his self-harm
history in any detail.
110. The doctor said that the man told her that he was okay at Camp Hill and they
discussed whether he wanted to share a cell. She recalled that he preferred
to remain in a single cell.
111. A prisoner on the wing who worked as an orderly (cleaner) recalled the man
coming onto the wing. He described him as very quiet and, although he
spoke when spoken to, he did not volunteer any information or engage with
people. He said that the man would come out at association (time out of cell
to mix with other prisoners) and watch people play pool although he did not
see him playing. The prisoner described the staff on the wing as helpful and
sympathetic but said the regime was poor and prisoners spent a considerable
amount of time locked in their cell.
112. The man wrote Prisoner A a short letter (postmark on envelope 15 May)
saying that it was a “shit hole” there, that he missed them and that some of his
stuff was missing. He asked him to write back soon. (Some items were left in
the cell at Lewes and were sent later to Camp Hill to be sent to his parents.)
113. A prison chaplain saw the man on 16 May in his cell as part of the induction
process for any registered Catholic prisoners. She spent about 15 minutes
with him and they spoke of his children and his accommodation needs upon
discharge. She said he was not very communicative or forthcoming but she
did not have any concerns about self-harm or suicide risks. She did,
however, mention to a member of staff that she felt he might need some extra
25
help on the wing but she could not recall who she spoke to. There is no
mention in the wing observation log book.
114. On 18 May, a CSRA was completed which stated that the man was to be
“locate flat and single cell” with the reason given as “high/medical single.”
115. Two days later, on 20 May, he was issued with a warning for smoking two
days earlier whilst on association, a routine response to anyone who smokes
outside the designated areas. The warning was issued by Officer H and
countersigned by SO B. In interview, the SO recalled the officer reporting that
the man had been very polite when he was issued with the warning which he
felt was unusual under the circumstances.
116. The same day, Nurse E recalled a very quick conversation with the man when
he came to the medication hatch in the afternoon. She thought from his brief
encounter that he said he was fine and she did not have any concerns about
him.
117. The man made five telephone calls to his parents between 14 and 19 May.
He described life at Camp Hill as a “shit hole” and “worse than anything he
has ever known”. My investigator listened to the calls and felt that he
sounded relatively upbeat and his parents said they were not unduly
concerned about him. They discussed him getting a visiting order (VO) and
he spoke of it being returned because he needed their dates of birth. On 20
May, at 6.19pm, he made his last telephone call to a female friend and they
spoke for about five minutes. She asked what it was like there and he replied
“shit” and, when asked whether he had made any friends, he said no. He
gave the address of Camp Hill so she could write in and he could send her a
VO. She told him about going to Canada for a couple of weeks and the
conversation ended quite abruptly when he said he had to go. (These calls
were routinely recorded and would not have been listened to at the time.)
118. OSG A was on night duty starting at 8.45pm on 18 May. At the start of the
shift, there was a handover from day staff but nothing was reported about the
man. During the night, the OSG’s duties included checking any prisoners on
ACCTs, answering cell bells and carrying out roll checks [counting all the
prisoners] at the start and end of the shift. At 11.20pm, he became aware that
the man’s television was turned up quite loud so he went to his cell. He said
that the man was sitting on the bed and when he asked him if he would turn
the volume down. He did so, without comment, and the OSG thanked him
and walked away. The prisoner in the neighbouring cell confirmed that he
had heard the volume of the television go up and the man being asked to turn
it down.
119. At 12.05am, the Orderly Officer, SO C, came onto the wing as part of his night
time checks of the prison and he and the OSG sat in the office talking until
12.30am. (The Orderly Officer is the most senior member of staff on duty at
night and is responsible for the prison. Both are permanent night staff and
have been employed for a considerable time.) At approximately 00.35am
when the Orderly Officer left, the OSG noticed that the volume of the man’s
26
television was up again and returned to his cell. He looked through the
observation flap and saw him sitting on the floor, with his head bent forward.
The OSG then noticed the noose attached to the top bunk. The OSG was
only steps away from the office and returned there to telephone the control
room to tell them a prisoner was hanging. (The OSG was carrying a radio but
said he was so near the office that it was his first response was to use the
telephone in there.)
120. The control room radioed the Orderly Officer who arrived at the cell very
quickly, having only just left the wing to return to the segregation unit a couple
of minutes earlier. The segregation unit is approximately 30 yards from the
cell and he ran, accompanied by at least two other officers. SO C opened the
cell door and staff quickly cut the ligature and laid the man down. The SO
said that the man’s face was bright red and he was cold to touch with a
degree of rigor mortis. He made a number of checks for a pulse but could not
locate one and asked the control room to call for an ambulance. The staff did
not attempt cardiopulmonary resuscitation (CPR).
121. According to the ambulance report, the paramedics were called at 00.41am,
were at the man’s side by 00.46am and certified his death at 00.50am. He
had left a short note addressed to his parents by his side and placed a photo
of his children next to it.
122. The prison contacted the police who agreed to go to the home of the man’s
parents to break the news. This was at about 4.00am. Very soon after this
visit, his mother contacted Camp Hill and spoke with a governor. Later that
afternoon, Officer I, from the Safer Custody Team, contacted the man’s
mother in his role as family liaison officer. He offered to collect her so that
she could come to Camp Hill and also to see her son at the Chapel of Rest.
She declined the offer but did agree to a visit from the FLO a few days later.
The prison offered the cost of the funeral.
27
ISSUES
123. The man had both complex physical and emotional difficulties. Whilst there
was not a clear understanding of his needs, there is significant evidence of
staff at Lewes interacting in a meaningful and supportive way towards him.
They were helped by some prisoners. Staff tried to persuade him on a
number of occasions to be moved to the healthcare centre but he always
declined. He made three further self-harm attempts after his initial serious
attempt in November, but these were less severe. I am particularly impressed
by the regularity of his contact with his personal officer which is something not
often seen in other establishments. However, there are a number of areas in
which staff at Lewes performed disappointingly.
ACCT management at Lewes
124. In his clinical review, the clinical reviewer discusses the man’s acts of self-
harm;
“on each occasion that he cut himself, an assessment of the event and
of his intent to attempt suicide or harm himself again was made.
Separately, these assessments all indicated low risk. Each individual
assessment following self-harm was adequate. However, there
appeared to be no attempt made to understand the triggers for him
harming himself, the circumstances of these incidents and whether a
theme or pattern would be established. I observed that in his case,
each individual assessment was conducted carefully and came to a
reasonable conclusion, but each focused only on the most recent
episode of self-harm.”
125. The man was on three ACCTs during his time at Lewes. Although he was in
contact with the mental health in reach team, and with medical staff for his
many physical needs, none of the reviews included any staff other than
discipline staff. These reviews should be multi-disciplinary especially when
the prisoner is already involved with medical staff. In each individual ACCT
there was no consistent case manager and rarely the same two staff
conducting the reviews. Although he was known to staff on his wing and they
would have been familiar with him, a case manager with an overview of him
should have been at each review. This indicates some poor practices in the
general management of the ACCT process.
The Governor of HMP Lewes should issue repeat guidance about the
management of ACCTs, ensuring multi disciplinary case reviews and a
consistent approach in the case manager role. The ACCT must be
monitored for quality.
126. On 16 April, staff attended to the man after he cut his left wrist. None of the staff
involved, which included a nurse and the duty manager, considered, or even
discussed, opening an ACCT. The guidance from Prison Service Order 2700
(Suicide prevention and self-harm management) is very clear:
28
“All acts of self-harm or statements of intent to self-harm must always be
taken seriously no matter what the perceived reason for the self-harm is.
Attitudes that see some people who self-harm as “genuine” and others as
“manipulative” are dangerous and should not be tolerated by managers.
Where the self-harm is goal-oriented, the prisoner should be helped to
find a more constructive way to meet their underlying need.
13.2 Follow-up actions and care for prisoners who have self-
harmed
In the event of any incident of self-harm staff must (where there is not
one open already) open an ACCT Plan. This must be done no matter
what the reason for the self-harm. Opening an ACCT means that the
individual will be interviewed by an ACCT Assessor who will talk with
them about what led up to the incident, what they were trying to achieve
and why and how they think further self-harm could be avoided or
reduced in the future. The care plan for someone whose self-harm was
not suicidal in intent will be different from one who is determinedly
suicidal, but they still require care.”
127. The ACCT process is not only a tool for those with active suicidal intentions,
but also for those who harm themselves. An ACCT should have been opened
regardless of how the action was perceived by the nurse, who felt that it was
not a serious attempt. The duty manager should have checked that an ACCT
was opened.
The Governor of HMP Lewes should remind all staff of the PSO
guidance in relation to when an ACCT must be opened.
The man’s physical health care needs
128. In his clinical review, the clinical reviewer comments that:
“The medical record is replete with accounts of the man falling,
collapsing, suffering from an epileptic fit and – on one occasion –
having an asthma attack. I found no information to indicate that his risk
from collapse (from fits or falling) and poor mobility were addressed
comprehensively.
Addressing his physical problems and managing him in a more
appropriate environment may have improved his physical and mental
well-being. I acknowledge that this is difficult in a prison environment.”
The Head of Healthcare at HMP Lewes should ensure that staff
adequately identify and manage physical health care needs and
communication difficulties for prisoners.
29
Identification of the man as a prisoner with disabilities
129. The man was identified as a prisoner with disabilities and, on 16 February, the
Disability Liaison Officer at Lewes completed a Disabled Prisoner Care Plan.
By this stage, he had been in custody for two and a half months. The
assessment concluded that he needed no assistance in any areas. Given the
help he was receiving on the wing from prisoners and staff this does not seem
to accurately reflect his situation. It is not clear from the form whether any
supporting information was sought from staff or healthcare and gives the
impression that the assessment may be a formality rather than an in-depth
enquiry.
The Governor of HMP Lewes should ensure that the Disabled Prisoner
Care Plan is completed in a timely fashion and with attention given to all
available records.
130. During his telephone calls to his family, the man described Camp Hill as a
“shit hole” and mentioned that he needed their dates of birth so he could send
out a visiting order. This appeared to be holding up his application and
preventing him from sending out a visiting order. Given that all this
information was already recorded in the system as his parents had visited
before, it seems an unnecessary demand on prisoners to provide this
repeatedly and particularly for him something he would have found difficult to
recall. Such a request would have impacted disproportionately on him and,
had he been more systematically identified as a prisoner with disabilities, I
hope that he would have received help from staff.
131. Unfortunately, the man’s parents received a visiting order six days after he
died and understandably were very upset by this. My investigator spoke with
the liaison officer at Camp Hill who looked into the matter and found that the
man had sent the order out on 20 May, the day before he took his own life.
The man’s medical record
132. The man arrived at Camp Hill with a temporary medical record. On 16 April, a
new medical record was started as the original one appeared to have been
lost. This second record remained in circulation and was the document which
travelled with him to Camp Hill. The investigator asked staff to see if they
could search for the original medical record and it was found in the archived
medical records file. (The record was sealed and had written on the outside
“released 3/01/09. However, the last record in it is recorded as 17 February.)
It is hard to believe that this action could not have taken place before his
transfer and, at the very least, upon his transfer. I do not know how regularly
misfiled medical records are but I would suggest that the Head of Healthcare
give some guidance to staff about what measures should be taken to find one
should it go missing.
The Head of Healthcare at HMP Lewes should remind all staff of the
importance of filing records correctly. In the event of a missing medical
record, guidelines should be issued about how to search for them.
30
133. One of the responsibilities of the healthcare staff is to complete the medical
section of the Prisoner Escort Record. This is usually a task done during a
night duty and involves checking their medical record. When the man was
transferred to Camp Hill, the PER said that he had no medical issues. Given
the extent of his extensive difficulties, it is difficult to understand how this can
have happened and I am disappointed the PER was not fully completed in this
area.
The Head of Healthcare at HMP Lewes should issue local instructions
on the correct procedures to be followed when a prisoner is transferred
and the information that should be made available to the receiving
prison on the PER form.
134. Given the complexity of the man’s medical difficulties and the numbers of
incidents of fits and falling he had had whilst at Lewes, it would have been
very beneficial if medical staff at Camp Hill had been provided with a
summary of his needs.
The Head of Healthcare at HMP Lewes should ensure that proper written
handovers are given to any receiving prison, especially when a prisoner
has ongoing medical issues.
Cell Sharing Information records
135. The man’s Cell Sharing Risk Assessment was marked with a comment that
he had threatened to set fire to his cell mate. My investigator has been
unable to find out what this refers to as there is no other record and none of
the staff interviewed knew what it meant. The comment contributed to him
being identified as being high risk, although he does appear to have been
allowed to share with prisoners after this incident. The information was
passed onto Camp Hill, even though it may have been inaccurate, and
although he was identified as high risk and did not want to share, it may have
penalised him unnecessarily.
The Governor of HMP Lewes should remind staff of the importance of
completing records accurately.
136. A security report had been completed on 30 April following a prisoner telling
staff that two prisoners were taking his medication from him. As a result, the
man was supervised when taking his medication. On 8 May, he was allowed
to share a cell with one of these prisoners. Although this was a move which
he agreed to, it does appear a somewhat risky policy. I make no
recommendation but the Governor will wish to consider whether any action
should be taken to ensure that prisoners do not share cells with a possible
bully.
31
Transfer from HMP Lewes to HMP Camp Hill
137. Once the man was sentenced and categorised as a category C prisoner, he
became eligible for transfer out to Camp Hill. The timing of the transfer is
organised by the OCA (Operations, Categorisation and Allocations
department) and staff on the wing are informed accordingly. From Lewes, the
transfer day to Camp Hill often occurs on a Tuesday and notification to the
wing can take place on the previous Friday or the Monday. Depending on
which member of staff my investigator to spoke to they explained that
prisoners are informed of the move by being handed a slip in person or
posted under their door. At least 24 hours warning is given, although it can be
longer, and this allows a prisoner the opportunity to speak with staff if they are
unhappy about the transfer. Staff said that the objection can be expressed to
a governor for them to deal with. It seems that he received his slip on the
morning of the transfer after hearing of the move the night before from
another prisoner. It is not clear whether this was a deliberate action on the
behalf of staff or an oversight. For the man, it meant he was not given the
appropriate amount of time to launch any objection to the move.
138. He was not an unknown quantity to staff on C wing at Lewes. They knew of
his self-harm history, his physical difficulties and how both he and staff relied
on other prisoners to help him. On the morning of the transfer, the view was
taken that he would resist going to Camp Hill and a situation developed where
use of force was used. (Staff completed the use of force paperwork.) The
senior officer wanted the transfer to happen without any problems and I
believe that the man was “tricked” into coming out of his cell. This meant that
he also did not have time to pack up his own things or say goodbye to his
friends. I do not believe that this situation was dealt with in an appropriate or
fair manner.
139. Despite being aware of his history and the concerns being expressed by
Prisoner A, an ACCT was not opened by staff at HMP Lewes even though this
would not have prevented the move or held up the transport van. Also, no
information was recorded on the PER to relay that use of force had been
used. Consequently, staff at Camp Hill were unaware of what had taken
place during that morning and his distress about being moved.
The Governor of HMP Lewes should issue local instructions on the
correct procedures to be followed when a prisoner is transferred and
the information that should be made available to the receiving prison on
the PER form.
Clinical care
HMP Camp Hill
140. Unusually, there are two clinical reviews attached to this report. The first
clinical reviewer’s review looks at the man’s time at Camp Hill and the second
clinical reviewer reviews his time at Lewes.
32
141. The first clinical reviewer’s review discussed two main points. Firstly, the man
did not attend for his supervised morning medication on 16,17, 18 or 20 May
at Camp Hill and although healthcare ff say that they rang the unit but he
refused and only attended evening sessions, their calls and his response
were not recorded anywhere. It was confirmed that a policy, prompted by his
death, was in the process of being written. The pharmacist present at the
panel review suggested that the implications of him not taking his medication
would be that he was more likely to suffer from a fit after two or three days.
Missing his anti-depressant medication would have had a long term effect.
142. Secondly, staff indicated that healthcare staff would normally inform wing staff
if a prisoner suffers from epilepsy, asthma or diabetes. The man’s form,
available to discipline staff, had ‘serious medical issues’ but they were not
specified.
143. Both these concerns were addressed with the one recommendation made by
the clinical reviewer and panel;
The Primary Care Trust should draw up a policy to identify prisoners at
HMP Isle of Wight who miss their medical appointments and medication
appointments. This is also to include identifiable conditions such as
epilepsy, diabetes and asthma.
144. The first clinical reviewer concluded that, in relation to Camp Hill, the man
received “equitable care as that received within the community”.
HMP Lewes
145. The second clinical reviewer’s review contains a number of recommendations
which can be read in full in the annexe. For the purpose of his review, he
spoke with the nurse consultant in Forensic Mental Health at HMP Lewes.
For his review, he obtained the man’s medical notes from the community and
wrote:
“Access to these records would have enabled the prison health service to
appreciate the man’s history of self-harm and substance misuse prior to
his respiratory arrest and his complex problems that followed his
respiratory arrest, both physical and psychological, in response to
dramatic changes in his circumstances as well as hypoxic brain damage’.
146. The clinical reviewer makes the following recommendation in relation to this
which I fully endorse;
HMP Lewes’ mental health service should request mental health records
for prisoners with a history of contact with mental health services.
147. Among his comments, the clinical reviewer suggested that ‘the provision of a
key nurse may have enhanced the clinical team’s understanding of the man’s
circumstances, contributed to the clinical formulation, and provided him a
33
single point of contact, a nurse with whom he could develop a therapeutic
relationship’.
148. The clinical reviewer made some very interesting comments about the
identification of mental disorder, the transfer from Lewes to Camp Hill and
drawn some conclusions. I repeat them here.
“A historical occupational therapy/speech and language therapy report
dated 2007 – available in the prison record – noted that the man had
difficulty planning and organising information and in social interaction
and behaviour, where he had a tendency to push boundaries. This
may indicate the presence of frontal lobe pathology, which may also
have had a bearing on his apparent tendency to emotional instability
and poor impulse control at times when he harmed himself. This is
suggested by his appearing to harm himself in response to relatively
trivial matters and frustrations when his demands were not met.
This would have presented particular difficulties with management, as
hypoxic frontal lobe damage is likely to have been irreversible at this
stage. However, treatment could have aimed to control the external
environment and provide appropriate, consistent support and
boundaries. A management plan formulated to minimise external
pressures would have been difficult to implement within a prison
setting, but a care plan designed to keep external stresses at a
minimum and provide a consistent clinical team may have been
beneficial.
An assessment by a psychiatrist would have provided the opportunity
to collate the man’s history and perform a mental state examination to
produce a comprehensive clinical formulation to inform management.
I discussed this with a colleague. At the time of the man’s
imprisonment at HMP Lewes, there were only two sessions of
consultant and two sessions of specialist registrar clinics weekly. This
dedicated that only prisoners with the most severe disorders or acute
presentations could be assessed by and receive aftercare from a
psychiatrist. My colleague agreed that it would have been highly
desirable for the man to have been assessed by a psychiatrist, in order
to collate a detailed history and produce a comprehensive clinical
formulation to inform management. He has been implementing a
commissioning review with the result that a new consultant has been
recruited to provide seven clinical sessions at HMP Lewes. He
anticipates that this will provide sufficient resources to enable the
clinical assessment and management of more prisoners, including
those with complex presentations like that of the man.
Regarding equivalence of care, my colleague was of the opinion that
HMP Lewes had been able to provide a high standard of care, but this
would not have been as comprehensive as a community mental health
34
team would have been able to provide because of the lack of a
psychiatrist and multidisciplinary team.”
149. With regard the transfer, the clinical reviewer wrote:
“The inmate medical record and the community mental health team
and substance team notes from Bognor Regis indicate that the man
found it difficult to adjust to new circumstances. Transferring him from
HMP Lewes to HMP Camp Hill may have resulted in his experiencing
considerable stress. That he was transferred nine days prior to his
death may well be significant.
A complete clinical formulation may have alerted prison mental health
staff to the possibility that he could tolerate transfer poorly. The
provision of a keyworker who had developed a therapeutic rapport with
him may have enabled its anticipation.
The transfer of vulnerable prisoners with poor coping mechanisms
should only take place when absolutely necessary, and with adequate
support structures in place.
My colleague said that his clinical team would have no influence over
the transfer of a prisoner, except if they expressed a ‘grave concern’,
for which they would have to provide evidence.”
150. The clinical reviewer makes 15 recommendations which should be considered
by the Head of Healthcare at Lewes. He concludes his report:
“While the man’s attempting suicide may not have been predictable in
the days before his death, there are a number of issues that could have
been addressed at an earlier stage in his imprisonment that may have
reduced the risk of his acting thus.
The absence of a mental illness does not necessarily equate to a low
risk of attempting suicide, particularly when a number of psychological
and social factors and stressors combine. Together, these can
engender a sense of hopelessness and futility. This is especially
hazardous in an individual with a propensity to risk-laden acts rather
than a tendency to approach staff to discuss unpleasant feelings and
ideas of self-harm.”
151. The man’s disclosure to the prison doctor at Camp Hill that he had been
withdrawing from drugs during his first few days at the prison is a puzzling
revelation. There is no evidence of this other than his own disclosure.
Neither Prisoners A or B indicated when asked that they had known him to
use drugs. I am unable to draw any conclusion except that, if he was
withdrawing, this would have affected his mood.
35
The discovery of the man
152. There is no inpatient healthcare facility or any healthcare staff available in
Camp Hill during the night. Two senior officers work alternate permanent
night shifts and, at the time of the man’s death, only one was first aid trained.
SO C was not up to date with his training (which has to be refreshed every
three years) and was not CPR trained although he described himself as
competent and knowledgeable. Upon discovering the man, he assessed his
condition and believed that all the signs indicated that he was dead. In
interview, he was asked about his understanding of when staff should or
should not attempt CPR. He responded:
“The first aid side of life is quite simple and it’s if a person shows no
signs of life via heartbeat or via breathing, then CPR should be used
until medical, proper qualified medical attend and I’ve got no problem
with that whatsoever. But not being trained, not being qualified then it’s
not my place to actually carry it out apart from obviously if I thought that
I could do it. But if it was blatantly obvious, which unfortunately it was
that the person was beyond resuscitation which in opinion, unqualified
that he was, there was no point to it whatsoever which the ambulance
crew when they arrived confirmed. If some degree of life or recent life
had been there then I would have had no problem whatsoever in doing
it but unfortunately he was beyond that, in my opinion.”
153. Despite his lack of up to date first aid training, I believe that SO C’s actions
were entirely appropriate. Following the man’s death, both permanent night
staff have now been trained in CPR. Had this not been the case, I would be
making a recommendation to this effect.
Family Liaison
154. The man’s parents were told at 4.00am of his death by police officers from
West Sussex. It is preferable for staff from the prison, or alternatively, staff
from the nearest prison to the family home, to break the news to the family in
person and this is policy guidance. A report into the death of another prisoner
in 2009 resulted in a recommendation regarding how best to inform the next
of kin. Given the time of night, and the limited number of staff on duty at night
in any establishment, it is understandable that Camp Hill made these
arrangements with the police. However, it should be noted that generally the
expectations are that prison staff will inform the next of kin.
36
CONCLUSION
155. At Lewes, the man appeared to settle and staff, recognising his vulnerability,
supported him very well. Whatever the motives of Prisoners A and B, it was
recognised that they consistently provided help and support for the man. Staff
often called on them on both a daily basis and when he was in particular
difficulty and at risk of harming himself. Having self-harmed very seriously
two weeks after his first remand to Lewes, he appeared to become more
comfortable and settled. The good practice at Lewes was tragically
undermined by the apparently unplanned transfer to Camp Hill. Lewes
prisoners regularly move to Camp Hill but I find it unfortunate that no
exception was made for a vulnerable prisoner such as the man. Furthermore
the transfer was carried out in a fundamentally flawed way. Not only was he
deprived of his opportunity to appeal the move, pack his belongings or bid
farewell to his friends, but he was moved after what can only be described as
a trick which persuaded him to come out of his cell. Then, and making matters
considerably worse, force was used to make him leave. Finally, none of this
was reported to Camp Hill and so no one there knew about the traumatic
experience that he had experienced. Sadly, at Camp Hill without his friends
and amongst staff who were unfamiliar to him and how he presented, he was
isolated and vulnerable.
37
FAMILY RESPONSE TO DRAFT REPORT
156. The man’s family received a copy of the draft version of the report as part of
the consultation period. His family told my family liaison officer that they were
angered and saddened by the findings and that it had been simply too painful
to read the report and annexes in their entirety. They feel he required
specialist help and the system failed to provide this. They feel that a lack of
information sharing between staff meant their son received inconsistent and
inadequate care and that little effort was made to understand his disabilities
and to engage him in activities he was physically able to do. They were
further concerned about the management of his medication and the decision
to transfer him to a prison that did not provide 24 hour healthcare, the
rationale being that this was not something he had relied on in the community.
His family strongly disagree. They explained that although he craved
independence, his disabilities prevented him from living independently in the
community. He lived in adapted housing where he relied on visits from carers
at least three times a day and daily help from his family. The family feel it is
apparent that he was deemed ‘fit for transfer’ without due consideration of his
healthcare needs or the ongoing support he required. The family were also
shocked to learn that prison officers are not required to have mandatory first
aid training despite being responsible for large numbers of prisoners. They
welcome the subsequent decision to provide CPR training for permanent night
staff at Camp Hill. The family feel that the way in which he was tricked out of
his cell prior to being transferred to Camp Hill was reprehensible and a
serious breach of his rights as a prisoner. They feel strongly that this can only
have added to his feelings of vulnerability, isolation and despair.
38
RECOMMENDATIONS
All recommendations, with the exception of number 7, were accepted. Number 7
was partially accepted. The proposed action is written in italics following each
recommendation.
1. The Governor of HMP Lewes should issue repeat guidance about the
management of ACCTs, ensuring multi disciplinary case reviews and a
consistent approach in the case manager role. The ACCT must be monitored
for quality.
ACCT management monitoring procedures are already in place including post
closure reviews and a further assessment during the Safer Custody meetings. Multi
disciplinary reviews will be further promoted by within the Safer Custody Strategy
and regular Safer Custody meetings.
2. The Governor of HMP Lewes should remind all staff of the PSO guidance in
relation to when an ACCT must be opened.
We will re-publish guidance on ACCT management. This will be further supported
by referral to the Safer Custody Toolkit, now accessible by all staff electronically. All
ACCT training to reinforce instruction on when an ACCT must be opened.
3. The Head of Healthcare at HMP Lewes should ensure that staff adequately
identify and manage physical health care needs and communication
difficulties for prisoners.
Each prisoner entering Lewes will receive a full health screen. Any issues identified
will be followed up through Mental Health, Drugs and Alcohol or Primary Care
Services. All care plans and referrals will be tracked through the System One
electronic medical records system now in place at HMP Lewes. All referrals to the
Mental Health In-Reach Team are now scrutinised by our resident consultant
psychiatrist.
4. The Governor of HMP Lewes should ensure that the Disabled Prisoner Care
Plan is completed in a timely fashion and with attention given to all available
records.
Disability Officer to be provided with sufficient opportunity to complete care plans in a
timely fashion including sufficient access to necessary and available records where
appropriate.
5. The Head of Healthcare at HMP Lewes should remind all staff of the
importance of filing records correctly. In the event of a missing medical
record, guidelines should be issued about how to search for them.
All medical records are now maintained electronically utilising System One; all paper
received is scanned into the system.
39
6. The Head of Healthcare at HMP Lewes should issue local instructions on the
correct procedures to be followed when a prisoner is transferred and the
information that should be made available to the receiving prison on the PER
form.
Local healthcare protocol will be produced stating what health information must be
included on each Prisoner Escort Record.
7. The Head of Healthcare at HMP Lewes should ensure that proper written
handovers are given to any receiving prison, especially when a prisoner has
ongoing medical issues.
When a receiving prison is ‘live’ with System One Electronic Records, there is no
need for a written paper transfer sheet – as records are electronically ‘push-pulled’
from one establishment to another. In the absence of System One, a full summary
extracted from System One will be printed and sent with the prisoner.
8. The Governor of HMP Lewes should remind staff of the importance of
completing records accurately.
Notice To Staff (NTS) to be published reminding staff on the importance of
completing records accurately.
9. The Governor of HMP Lewes should issue local instructions on the correct
procedures to be followed when a prisoner is transferred and the information
that should be made available to the receiving prison on the PER form.
Instructions to be provided to those working in Reception on the use of the PER,
including the assurances required that all necessary and relevant information is
accurately documented.
10. The Primary Care Trust should draw up a policy to identify prisoners at HMP
Isle of Wight who miss their medical appointments and medication
appointments. This is also to include identifiable conditions such as epilepsy,
diabetes and asthma.
Guidelines are in draft form. Further amendments are in the process of being
included which will then be agreed for working draft. Full discussion at management
meeting 24 November 2010 for working draft to be implemented.
11. HMP Lewes mental health service should request mental health records for
prisoners with a history of contact with mental health services.
When a prisoner is identified, through first-night reception healthcare screening
processes to have had previous contact with the mental health services, the Mental
Health In-Reach Team will make a determined effort to obtain previous records and
information. The Nurse Consultant for Mental Health is currently in communication
with the neighbouring Mental Health Trust to gain access to Electronic Care Planning
Approach (ECPA).
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