Individual at Belmarsh

Investigation into the death of a man
whilst in the custody of HMP Belmarsh
in June 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2011
This is the report of an investigation into the death of the man. The man was found
hanging in his cell at HMP Belmarsh and was pronounced dead by paramedics and
the prison doctor. He had been in custody for nearly six months and was waiting to
be sentenced. The man was 25 years old.
I would like to offer my personal condolences to his family, friends and everyone
affected by his death. I am sorry that my report has been delayed and I regret any
additional distress which this has caused.
The investigation was undertaken by one of my investigators. In addition, the
investigations manager from NHS Greenwich, and an independent General
Practitioner, conducted a clinical review of the care received by the man. I am
grateful for their contribution to the investigation. I also thank the Governor of
Belmarsh and his staff for their participation in the investigation.
Having appeared in court on 25 January 2010, the man was remanded into custody
at HMP Pentonville. There were immediate concerns that he would harm himself
and suicide monitoring procedures were put in place to ensure that he was
supported. The man complained that he heard voices and felt depressed. He was
prescribed medication but refused to take risperidone because of the side effects.
The support procedures were closed on 11 March.
On 22 March, the man transferred to HMP Belmarsh, where he appeared to settle
well, with staff reporting no worries about his behaviour. On 2 June, he made two
telephone calls to his ex-girlfriend (the victim of his offences) when they discussed
their relationship problems. Later that day, at around 2.45pm, a fellow prisoner, who
had noticed that the man had not come out of his cell for his cleaning job, went to
check on him. The man was discovered hanging in his cell. The man had given no
indication to staff or other prisoners that he intended to harm himself.
My report makes two recommendations relating to repeat prescribing and obtaining
information at reception.
The version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman August 2011
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CONTENTS
Summary
The investigation process
HMP Belmarsh
Key events
Issues
Conclusion
Recommendations
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SUMMARY
1. After appearing at court on 25 January 2010, the man was remanded to HMP
Pentonville. He had a history of self harm and depression, and depended on
both alcohol and cocaine. He had continually punched himself while he was at
court and on the way to Pentonville, and suicide support procedures were put in
place when he arrived to ensure that he was monitored and supported
appropriately. A referral was also made to the mental health team. He said
that he had nothing to live for and wanted to stop hearing the voices in his
head. He was placed in a double cell and observed at regular and frequent
intervals.
2. On 11 March, the support procedures were closed. During a post closure
review, held a week later, the man said that he no longer had any suicidal
thoughts and felt positive about the future.
3. The man attended Basildon Crown Court on 22 March, and was taken to HMP
Belmarsh after the hearing. He went through the normal reception screening
and induction process. It was noted that he had previous substance misuse
problems, drug induced psychosis, had self harmed and had been supported
under the suicide support procedures whilst he was at Pentonville. However at
this time, he gave no indication that he might want to harm himself.
4. In the next few weeks, the man settled into the prison regime at Belmarsh.
Staff reported no concerns with his general well-being and he went on to be
employed as a wing cleaner.
5. On the morning of 2 June, he spoke to his ex-girlfriend on the telephone.
Having reviewed the content of these conversations after his death, he and his
ex-girlfriend seem to have been having relationship problems. Another prisoner
saw how upset the man was after speaking to his ex-girlfriend, but did not think
that he would harm himself.
6. Later that morning, the man collected his lunch as usual. He was in his cell
alone during the lunch time break (approximately 11.30am -12.15pm) and was
seen in his cell by staff when they carried out a routine check. At around
2.45pm, a fellow prisoner looked through his cell door flap as he had not seen
him after the cells were unlocked. He saw the man hanging by a ligature from
the ceiling light fitting in his cell and immediately called for staff assistance.
Staff went into the cell and called for medical assistance. Cardio pulmonary
resuscitation (CPR) began and the paramedics arrived to take over. However,
the man was pronounced dead at 3.21pm.
7. I make two recommendations as a result of this investigation. They relate to
obtaining information at reception and repeat prescribing of medication.
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THE INVESTIGATION PROCESS
8. The investigation into the man’s death was opened at HMP Belmarsh on 8 June
2010 by one of my investigator, assisted by the manager of Greenwich. They
met the Governor of Belmash and some of his staff. Notices of investigation
and terms of reference had already been sent to the prison, inviting anyone with
any information to contact the investigators.
9. They later met and formally interviewed a number of prison staff. They visited
all parts of the prison including the house block where the man lived. They also
met representatives from the Prison Officers’ Association and the Independent
Monitoring Board and met the prison liaison officer. I thank her for her
assistance throughout the investigation.
10. Regrettably the investigation was delayed throughout because of difficulties
arranging suitable interview times for staff working at the prison. This has
already been brought to the attention of the Governor. Also some staff were
not available to be interviewed and information was obtained from alternative
sources.
11. The man’s prison records, including his medical record, were made available
during my investigators and his assist’s initial visit to the prison. Additional
documents were provided on their return visits to the prison to interview staff.
12. A clinical review of the man’s medical care was commissioned from NHS
Greenwich. Although there was a delay in its completion, I would like to thank
the investigations manager from Greenwich and the clinical reviewer for their
contribution to the investigation. Their report has been disclosed to the Primary
Care Trust.
13. One of my senior family liaison officers contacted the man’s family to inform
them of the investigation. My family liaison officer and my investigator
subsequently visited the man’s mother at her home where she raised the
following concerns:
• Some items of the man’s personal possessions were missing when his
property was returned to the family.
• A letter that was sent by the family to the man in prison was later returned to
them through the post and marked “PB not here”. The family were upset by
this lack of sensitivity.
• Why did the prison contact the man’s partner to inform her of his death as she
was not his next of kin?
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BACKGROUND
HMP Belmarsh
14. HMP Belmarsh opened on 2 April 1991 and is a local prison, serving primarily
the Central Criminal Court and its feeder magistrates’ courts in south east
London. In addition, the establishment serves Crown and magistrates’ courts in
south west Essex. Belmarsh has a dual role, in that it also holds category A
prisoners. There are four residential house blocks and a High Security Unit
within the prison.
HM Chief Inspector of Prison’s report
15. The most recent inspection of Belmarsh by Her Majesty’s Chief Inspector of
Prisons was an unannounced full follow-up inspection in April 2009. In a report
published in December 2009, her comments included:
“Suicide and self-harm prevention was taken seriously, and there was
some good work, but with a tendency to over-medicalise the issue. Over
half the prisoners at Belmarsh said that they had at some time felt unsafe
there, and the prison’s own bullying survey had revealed low levels of
confidence in the anti-bullying system.
“Relationships between staff and prisoners had improved, but were still
mixed. Most interactions we observed were good, particularly on the first
night and drug treatment units, and more prisoners said that there was a
staff member they could turn to.
“Healthcare services had deteriorated since the last inspection, and there
was an urgent need for re-engagement between the prison and the
primary care trust (PCT). Mental health provision had decreased
considerably, and the excellent and much-needed Cass unit was under-
used and under threat. Primary healthcare in general was in some
disarray, with the ending of the current GP contract, poor management of
clinical records and some serious deficiencies in pharmacy services.”
Cell Sharing Risk Assessment (CSRA)
16. In order to make sure that unsuitable prisoners do not share cells, a cell sharing
risk assessment is completed by reception staff when a prisoner first arrives at
the prison.
Counselling, Assessment, Referral, Advice and Throughcare (CARATS)
17. Organisations specialising in the treatment of substance abuse have drugs
workers based in most prisons. CARATS workers run programmes, and can
offer counselling, support and referral to rehabilitation centres to prisoners and
on release. Access to CARATS is voluntary, by application.
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Critical debrief
18. A critical debrief takes place after a serious incident. It gives the staff the
opportunity to understand the incident in greater detail, review their feelings and
reactions after a traumatic incident. Benefits include being able to discuss their
experiences in a safe and confidential environment.
Cut down tools
19. Each officer and member of healthcare staff who is in contact with prisoners
carries an anti-ligature knife. They are knives which are specially designed to
cut through ligatures in a safe manner.
Emergency response codes
20. Emergency codes are used to summon staff to deal with a particular situation.
If there is a medical emergency, the call “Hotel 99” (which refers to healthcare)
is put over the radio. This refers to life threatening situations such as hanging,
severe blood loss or cardiac arrest. Such emergency situations require
immediate attention from healthcare staff as the prisoner cannot normally be
escorted to the healthcare centre for treatment.
21. Healthcare staff have emergency bags located around the prison. They contain
life support equipment which includes airways, ambu bags (breathing aid),
oxygen, needles and syringes. There are 12 defibrillators located around the
prison.
22. The general alarms are linked to the Control Room. When the button is
pressed (the buttons are found on the wing landings), the Control Room
broadcasts the location across the radio network throughout the establishment
so that staff from other areas can respond.
Listeners and Insiders
23. Listeners are prisoners trained by the Samaritans to provide a confidential
service for other prisoners. They do not offer counselling but offer support,
particularly for prisoners at risk of self harm.
24. Insiders are prisoners who volunteer to work in the First Night and Induction
wing and Reception, welcoming new prisoners and explaining the processes
they will encounter in the early days of custody.
Mental Health In-Reach Team
25. The In-Reach team offers a mental health service for all prisoners who have
enduring mental illnesses. They also treat and support prisoners who have
mental health problems, offering intervention in crisis situations. The team
supports prisoners who are at risk of harming themselves and attend most of
their review meetings.
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Person Escort Record (PER)
26. The police, courts, escort and prison services have an agreed procedure for
sharing information about prisoners as they are moved between their
establishments. It is essential that those responsible for the prisoner are made
aware of any risks or vulnerabilities. In particular it is essential that known risks
of escape, assault, suicide or self harm or harassment are communicated to
those with responsibility for the prisoner; to protect prisoners, staff and the
public. It is also essential that any new risks that arise during a movement are
recorded and flagged up. The PER is the key method for ensuring that
information about the risks posed by is always available to those responsible for
their custody.
Reception and induction
27. A Cell Sharing Risk Assessment (CSRA) is opened by a reception officer who
completes the basic details. The form is handed to the First Night Centre staff
where a confidential interview is conducted. The document is then passed to
healthcare staff. The CSRA is intended to provide consistent and continuing
risk assessment regarding sharing cells. While primarily aimed at establishing
the level of risk of prisoners sharing cells, it also includes other occasions when
space may be shared, for example when a prisoner asks to see a Listener.
28. Reception staff do not routinely have access to a prisoner’s past records and so
the prisoner is the main source of information. If a prisoner has transferred
from another establishment, his past record usually arrives with him which
should include the PER form.
29. The initial healthcare screen concentrates on the prisoner’s immediate well-
being, their mental health, risk of self harm or suicide and any drug or alcohol
withdrawal or detoxification issues.
30. All new prisoners are located on the induction wing. They are asked whether
they have any immediate concerns, such as disability, their offence and general
well being. The induction includes a further assessment, medical screening,
and input from the education and offender management units. Prisoners are
given a new reception pack, and telephone pin numbers and visiting
arrangements are explained.
Roll check
31. The roll check is the physical count of the number of prisoners on each wing
within a prison. Roll checks occur on a number of specified occasions during
the day and night, and staff sign that the roll is correct. Staff carry out a
physical head count to ensure that the prisoner is in his cell and the cell door is
locked. If they cannot see the prisoner, staff must open the door to investigate
further until they are satisfied that the person is in the cell.
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32. Local procedures at Belmarsh state that roll checks should be conducted at the
following times:
• 6.00am by the night staff before handing over to day staff
• 12.30pm (11.45am on Fridays) at lunchtime lock-up
• 5.15pm at the end of the core day, following activity/association
• 8.30pm (Monday to Thursday) at the end of the association
• 9.00pm at the end of the working day by the late patrol officer
Suicide and self harm monitoring procedures
33. The Assessment, Care in Custody and Teamwork (ACCT) procedures aim to
help and monitor prisoners at risk of harming themselves. The key aims of
ACCT are to create a safe and caring environment, identify prisoners’ individual
needs, and provide individual care and support before, during and after a period
of crisis. Once the ACCT procedures are closed, a post closure review should
take place within seven days.
34. Since my office took responsibility for investigating deaths in custody in 2004,
there have been seven previous self-inflicted deaths at Belmarsh.
Recommendations relating to record keeping have been raised in two of these
reports.
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KEY EVENTS
Events at HMP Pentonville prior to the man’s arrival at HMP Belmarsh
35. The man appeared at Havering Magistrates’ Court on 25 January 2010 and
was remanded into HMP Pentonville. He was charged with wounding and
grievous bodily harm and his ex-girlfriend was the victim of the alleged offence.
He was assessed by a prison doctor who noted that the man had a history of
self harm, depression and depended on both alcohol and cocaine. The ACCT
suicide and self harm support procedures were put in place as the man had
continually punched himself at court and on the way to Pentonville. He had
also hit his head with his fist and the wall whilst at the police station.
36. The following day, an ACCT review and care plan was completed. The care
plan said the man should be located in a double cell with hourly observations by
staff, and he should have unlimited access to the telephone and listeners if he
requested them. The man said that he had “nothing to live for” and wanted to
stop the voices he heard in his head. He was homeless and said his
relationship with his ex-girlfriend was in trouble. Staff made a referral to the
mental health team. In addition, the man agreed to apply to St Mungo’s (a
housing charity) for help with housing, to contact his family regularly and to see
the doctor for medication. The ACCT was to be reviewed on 2 February.
37. Later that morning, the man poured hot water on his leg, which he had also cut.
Staff took him to the healthcare treatment room where the cuts were dressed
and plastered and he was seen by the doctor. The man said he had been
having auditory hallucinations since before Christmas, the symptoms having
started after his relationship with his ex-girlfriend came to an end. The doctor
noted that the man was sleeping poorly, had lost his appetite and had lost
weight since Christmas.
38. The man was assessed by a Counselling, Assessment, Referral, Advice and
Throughcare (CARAT) worker on 27 January. The CARAT records stated that
he started using cocaine in October 2009 due to the breakdown of his
relationship. He said that he used between £251 and £500 of cocaine every
week and drank 25 units or more of alcohol a day. Although the man was not
thought to require further formal CARAT intervention, he was referred to
Alcoholics Anonymous and the alcohol workshop. The CARAT worker noted
that the man should be referred immediately because he had harmed himself.
She contacted the healthcare department with these concerns.
39. The man was subsequently assessed by a member of staff from the psychology
department. He said that he felt very low and had nothing to live for, although
he had no current plans or intent to harm himself. A referral for counselling was
made. Hourly observations continued and he was prescribed risperidone
(which is commonly used to treat schizophrenia and schizoaffective disorder)
and fluoxetine (an antidepressant).
40. The man was seen the following day by a CARAT worker who said that he
appeared more relaxed. He told the CARAT worker that he had been given
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sleeping tablets by the doctor but was worried they were being stopped that
night and he might start hearing voices again.
41. On 29 January, prison Doctor A conducted a mental health review with the man
and described him as stable. The man said he was not sleeping well, which
usually led to him to hearing voices. He talked about his background and family
life and denied having had any previous contact with a psychiatrist or
psychologist. The doctor increased his risperidone prescription and planned a
further review for two weeks time.
42. The ACCT support procedures remained in place for the man. At his next
review, held on 2 February, he talked about his family circumstances and life
history. He was still taking his medication. He was very talkative in the
meeting, said that he accepted that his relationship had ended and wanted to
get on with his life for his children’s sake. At the end of the review, it was
agreed that the ACCT document should remain open and his observations
were to be reduced to every two hours.
43. The man completed his alcohol detoxification on 5 February. He told staff
during the day that he was annoyed because his ex-girlfriend had sold his work
tools. After talking to staff, the man calmed down and started to slowly come to
terms with the news. He saw a doctor that day as was still suffering from poor
sleep and was prescribed zopiclone (used to treat insomnia).
44. On the evening of 8 February, during the ACCT checks, the man was found
attempting to commit suicide. He had made a ligature from bed sheets to hang
himself. He was taken out of his cell and an ACCT review was carried out
immediately with the man, a senior officer (SO) and a principal officer on the
wing. The man was very tearful, distressed, and said he wanted to “end it all”.
He was moved into healthcare where, to keep him safe, he was constantly
watched by a single member of staff.
45. On 9 February, the man discussed the previous day’s events with a healthcare
worker. He told the nurse that, when he was in the community, if he took
alcohol and drugs he would usually “blank out” and find himself in a police
station the next day. He disclosed that he had previously been admitted
himself to hospital. The man added however that he wanted to get help now as
he had two children to look after.
46. Later that day, another SO and a doctor completed an ACCT review. The man
appeared to be relaxed and settled but the doctor wanted the constant watch to
continue due to his attempt to harm himself the day before. Also, he had not
yet been properly assessed by the mental health team. The doctor increased
his risperidone prescription and his other medication was to be reviewed. An
ACCT review was planned for the following day, and a doctor from the mental
health team was asked to attend.
47. At the ACCT review the next day, it was noted that the man demonstrated a
good understanding of his self harm attempt which had led to his healthcare
admission. He said that he wanted to get better. The doctor noted that the
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man had no major problems and was eating and sleeping well. He was
concerned about the pending court case and his relationship with his ex-
girlfriend, but he denied having any active thoughts of harming himself. The
doctor advised that the ACCT support should continue with the man’s
observations reduced to every four hours. The next ACCT review was
scheduled to take place on 17 February.
48. On 10 February, the man was reported by staff as eating and drinking well and
they did not see any more incidents of self harm.
49. A mental health review took place on 15 February. The doctor said that the
man appeared depressed, had a history of alcohol and substance abuse and
continuing auditory hallucinations. His risperidone medication was increased
again and his antidepressant medication was to be reviewed in due course.
50. In the ACCT review on 17 February, the man said that he was hearing voices
which occasionally told him to harm himself. He said however that he had no
intention of doing so. He was participating in association and agreed to attend
cookery classes. The man said that he appreciated the monthly visits from his
family. The ACCT remained open and a review was scheduled for 24
February.
51. On 19 February, it was noted on the ACCT form that the man had red marks on
his cheek and forehead. He had made them with a broken plastic fork, which
he had thrown away. He said that his medication was working but, when it
wore off, he saw “little men”.
52. Five days later, on 24 February, the man was interviewed by a CARAT drug
worker. He spoke about wanting to get fit and overcome his drug problems for
the sake of himself and his children. He wanted to complete the relapse
prevention work and was given work by the CARAT worker to do in his cell.
However, as the man was in healthcare, he was unable to attend the relapse
prevention workshop.
53. Later that day, an ACCT review was conducted. The man and two members of
staff, including a nurse, attended. The man discussed his concerns about
having access to his children. He admitted to hearing voices but said that the
medication was helping. His medical records noted that he continued to hear
voices which brought on panic attacks, and his dreams caused him to have an
erratic sleep pattern. The man was however keeping himself occupied by
helping to paint the ward. The next ACCT review date was set for 3 March
54. On 1 March, the man had a mental health review. He was reported as having
an erratic sleep pattern, agitation, low mood and ongoing suicidal thoughts
(although he said that he had no plans to act on them). He said that he was
having fewer auditory hallucinations and asked for a test for Attention Deficit
Hyperactive Disorder (ADHD). He said that he was missing his children as he
had not seen them for about six weeks.
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55. Later that day, the man smeared himself with faeces and told staff that he was
worried about his forthcoming court appearance on 3 March. He was given
support and reassurance by the healthcare staff. The following day, his records
noted that he was tearful and anxious.
56. The man appeared at Havering Magistrates’ Court on 3 March and was
remanded back to Pentonville later that day. He was seen by a doctor on his
return, who noted that the man remained unpredictable and easily irritable if his
needs were not met. The doctor continued his current medication and the man
remained on the healthcare wing. Later that day, he seemed positive, believing
that he would not get a long sentence. After another ACCT review that
evening, the next review was set for 10 March and a mental health worker was
invited to attend.
57. On 10 March, the man complained that his risperidone medication was causing
him side effects. He was due to have an ACCT review, but this was postponed
as staff were not available.
58. The postponed ACCT review took place on 11 March. The man, a senior
officer, a prison officer and two nurses attended. The man was friendly and
approachable and said he had not harmed himself for a long time. He wanted
to complete an anger management course and move on, as he believed that he
would not benefit in any way from being located in healthcare wing. The staff
were content with the man’s well being and so the ACCT document was closed.
59. At a mental health review the next day, the man again denied having any
psychotic symptoms or thoughts of wanting to harm himself. He had refused to
take his risperidone medication for two days and this was discussed at the
meeting. The man said that it made him feel anxious and asked for valium to
be prescribed instead.
60. Over the next couple of days, the man continued to refuse his night medication.
He also became more vocal about his opinions of healthcare staff. He said that
there was nothing wrong with him or his behaviour and he wanted to leave
healthcare. A follow up mental health review took place on 15 March where it
was noted that the man’s behaviour had become more challenging since he
had refused his risperidone. He was still receiving fluoxetine.
61. On 17 March, the man was seen by a doctor who noted that he had not taken
his risperidone for seven days because he said it caused side effects. He was
not hearing voices anymore, nor did he have any thoughts of wanting to harm
himself. The doctor assessed the man as fit to leave healthcare and move to a
residential wing and his risperidone was to be discontinued.
62. The man was moved from healthcare to a residential wing the following day.
The ACCT post closure review was held the same day with two senior officers
present. The review noted that he had no suicidal thoughts and was positive
about his future. The ACCT therefore remained closed.
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The man’s transfer to HMP Belmarsh
63. On 22 March, the man was escorted from Pentonville to appear at Basildon
Crown Court. He was convicted of wounding and grievous bodily harm but not
sentenced. Following his court appearance, he was transferred to HMP
Belmarsh.
64. He was interviewed in reception by Officer A. (Officer A was one of the staff
who was unavailable to be interviewed by the investigators.) Officer A carried
out the initial reception interview with the man. He also completed a cell
sharing risk assessment (CSRA) on which he assessed the man as “medium”
risk. He noted “Smoker stated that he would harm other prisoners if he had to
share with them. SIR [Security Information Report] submitted”. The SIR also
noted that the man “stated that he had medical issues”.
65. As part of the reception process, the man was interviewed by nurse A. Nurse A
told the investigators that he would have had the man’s medical records with
him and interviewed him to check his immediate medical needs.
66. The man said that he was being prescribed fluoxetine. However, as he had left
Pentonville that morning, he had not received his daily dose. Nurse A said that
this was not an immediate concern as fluoxetine builds up in the system so a
patient could miss one dose without suffering any adverse effects. He referred
the man to the doctor to ensure that fluoxetine was prescribed and because he
had previously been prescribed rispiridone.
67. Officer B was the diary officer on duty. She checked the prisoner’s core
records for any relevant risk indicators (drugs, self harm, violence, which are
then written into their history sheet on duty). She did not meet the man but she
checked his core records and Prisoner Escort Records (PER) for anything of
relevance. The man’s PER mentioned violence and Officer B added this to his
prison history sheet. When asked by the investigators if she recalled receiving
information about the ACCT procedures, Officer B said that she did not. She
said that, had she received such information, she would have noted that he
“was on an open ACCT now closed”, thus making sure that other staff knew
what had happened previously. (The man’s ACCT paperwork was not received
at Belmarsh until eight days later on 30 March.)
68. The man was taken to the induction wing, house block three. He was
interviewed by Officer C, who completed an induction passport by collecting
information about his immediate needs. She highlighted mental health issues
as he said he was suffering from depression. She also noted that he had been
taking risperidone but had stopped because of the side effects. The man said
that he had tried to hang himself in January and had been supported by the
ACCT procedures whilst he was at Pentonville. However, he said that he had
no current thoughts of harming himself. From her assessment, Officer C said
she had no concerns that the man was at risk. She did not, therefore, open an
ACCT although she did tell the nurse on duty about these matters.
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69. The healthcare officer on duty, Nurse B, interviewed the man next and referred
him to the mental health team. (Nurse B was unavailable for interview during
the course of the investigation and the investigator could not find a copy of the
reception healthscreen.) The reason for referral was noted as the man’s
statement that he had schizophrenia and was taking risperidone and fluoxetine.
The nurse noted that the man had misused drugs in the past and questioned
whether he was experiencing a drug induced psychosis. Nurse B also noted
that the man had attempted suicide and had previously burnt his right foot.
70. The man was seen by the prison doctor and reassured. Shortly after this
screening, he would have been taken to his cell. There were no concerns
noted about his first night at Belmarsh.
71. All new prisoners have an induction talk to familiarise themselves with the
prison. The man’s induction continued the following day, 23 March. He was
seen by Officer D who completed a cell sharing risk review as the man’s CSRA
had been assessed as a “medium” risk when he arrived. The man maintained
that he did not want to share with prisoners such as “substance abusers”. The
CSRA subsequently remained as medium risk. Officer D noted that the man
had attempted suicide at Pentonville but had no current thoughts about harming
himself.
72. The man also had a secondary health assessment but his medical records, do
not identify which healthcare officer carried it out. The record was made by an
IT data summariser employed by NHS Greenwich PCT. From the investigator’s
enquiries, it is likely that the secondary assessment was also carried out by
Nurse B. The entry noted that the man had depression and was taking
fluoxetine and zopiclone. Nurse B noted that the man felt emotionally unstable.
73. The investigators interviewed Nurse C, the Mental Health In-Reach Manager.
The man’s mental health referral was discussed by the mental health team on
23 March. They were doubtful about the diagnosis of schizophrenia, noting that
it was rare for risperidone to be stopped and fluoxetine (an anti-depressant) to
be substituted. Nurse C attempted to see the man on 24 March to obtain
further information. However, he was unavailable as he was having an
induction talk.
74. Nurse C telephoned Pentonville’s mental health in-reach team and was told that
the man had been assessed but that schizophrenia had not been diagnosed.
His symptoms were described as due to poor coping skills and occasional
anxiety problems rather than schizophrenia. Nurse C knew that the man had
been supported by the ACCT procedures even though his medical documents
and ACCT documents were not yet available.
75. Nurse C referred the man to the Occupational Therapy Department so that he
would receive support and help with effective coping skills. (The occupational
therapist later made an appointment to see the man, but he failed to attend.)
76. On 26 March, the man referred himself to the Counselling, Assessment,
Referral, Advice and Throughcare (CARAT) team. A CARAT worker, told the
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investigators that he interviewed the man on 9 and 27 April when he made both
an initial and a comprehensive substance misuse assessment.
77. The man told the CARAT worker that he had last used cocaine in January
2010. He said that feeling stressed and being in a low mood were triggers for
taking the drugs. The assessment suggested that the man had high treatment
needs and an increased risk of taking drugs. A care plan was drawn up to
address these risk factors and increase his understanding in order to prevent a
relapse. The CARAT worker referred the man to the prisons drug treatment
programme, a Short Duration Programme (SDP) and the integrated drug
treatment system (IDTS) group work. (Although he was assessed as suitable
for the SDP on 19 May, he would have been unable to attend as he was due in
court.)
78. Prison Doctor B continued the prescription for fluoxetine, as well as prescribing
nytol (a sleeping tablet) for the man. He told the investigators that he wrote
repeat prescriptions at the request of nursing staff, and did not see or examine
the man. The doctor said that it was impossible to review the whole medical
record each time that a repeat prescription was requested and he would follow
the initial treatment plan decided at the reception healthscreen by the doctor
and nurse. Any necessary referrals would also have been made at that stage.
79. Senior Officer A (SO) had frequent contact with the man on house block three.
He described the man as a quiet young man who presented no problems to
staff. He settled on the wing and soon became employed as a wing cleaner.
Officer E concurred with the SO A’s view of the man, describing him as a happy
and polite individual. The man also worked in the servery where he interacted
well with both staff and other prisoners. Due to his work activities, the man was
out of his cell a lot of the time and Officer E said there was never an issue
about his behaviour.
80. The man’s first cellmate who shared the cell with the man for about four weeks
until about a week before the man’s death. He described the man as a “bubbly
fellow” who everyone knew. He did not speak about his time at Pentonville,
including the suicide attempt, and the man’s cellmate did not know if he took
any prescribed medication. The man did confide about his relationship
problems with his ex-girlfriend and his worries about losing his children. The
man was also concerned about the length of sentence which he might have to
serve.
81. On 27 May, the man telephoned his mother at 4.29pm. (The prison provided
the investigators with the typed transcript of the man’s telephone calls which
were not monitored at the time.) They had a five minute conversation about his
ex-girlfriend and their children. The following day, at around 4.40pm, the man
telephoned his ex-girlfriend and they spoke about their relationship and its
problems. The man said that he missed both her and their children.
82. Five days later, on 1 June, the man made two more telephone calls to his ex-
girlfriend at 2.57pm and 3.17pm, both for about ten minutes. The first call
sounds light hearted and the man spoke to his children. During the second
16
conversation, the man said that he had seen an officer from the public
protection unit. His ex-girlfriend had notified the police that he had written to
her, something he was not allowed to do as she was the victim of his crime.
The letters were returned to him. His ex-girlfriend told him that she had given
this information to the police some months ago. She said that she was happy
to receive correspondence from the man now, so that he could send letters and
cards for their children. Their conversation appeared to be friendly and the man
said that he hoped that she did not forget him whilst he was in prison.
Events on 2 June 2010
83. The man’s second cellmate was moved to house block three around the
beginning of May where he shared a cell with the man after cellmate A moved
to another wing. He was employed in the reception area, where he worked
each day between 9.00am to 8.00pm, remaining there during the lunch period.
84. Officer F was the officer in charge of spur 1 that day. She told the investigators
that at about 8.00am, as soon as the man was unlocked from his cell, he asked
her to contact the public protection unit. He said that he was worried about
what they had told him about ending the contact with his children. The man
also submitted three applications to attend courses, namely the Thinking Skills
Programme, Victim Awareness and Anger Management. Officer F sent off his
applications that morning. She also telephoned the public protection unit and
was told that the man could have contact with his children because he had now
been convicted. This information was passed to him later that morning, which
he was happy about.
85. The cleaners’ cells, including the man’s, are left unlocked until lunchtime and
they can leave their cells and use the telephones whenever they wish. The
man’s second cellmate said that he and the man had a cup of tea together
when they woke up and the man said that he intended to telephone his ex-
girlfriend. The cellmate knew they were having relationship problems and, the
previous night, the man was “ranting and raving” about things which he
intended to resolve after being released. The cellmate talked to him about the
situation and, after a while, he appeared to calm down. The man also said that
he had had an argument with his mother a few days ago about his relationship
with his ex-girlfriend. However, when the cellmate left their cell for work at
about 9.00am, he had no concerns about the man who seemed “absolutely
fine”.
86. The man made two consecutive telephone calls to his ex-girlfriend that morning
timed at 11.06am. He said that he was getting help with his substance misuse
problem and thought that he might receive a six year sentence. In the second
conversation, the man learnt that his ex-girlfriend had a relationship two months
previously with someone who he knew. Although he was upset, their
conversation appeared to end on a more positive note, with talk of a possible
reconciliation.
87. After speaking to his ex-girlfriend, the man went to prisoner A’s cell (which was
on the same landing near the telephones) to speak to him. The prisoner told the
17
investigators that the man was angry and, whilst complaining about his ex-
girlfriend, kicked the cell toilet door in frustration. The prisoner managed to
calm him down and they both returned to the man’s cell. Here, the prisoner
made them both a cup of coffee and they played a game of cards. The man
remained angry for a while but calmed down by the time when lunch time
approached.
88. Prisoner B saw the man after he spoke to his ex-girlfriend on the telephone.
The man told him about their conversation. He said he and other prisoners
spoke to him about how he felt and tried to advise him. The prisoner said that
he did not think the man was suicidal and “it was a major shock” when he heard
that he had died.
89. Prisoner C lived in the cell next door to the man and had spoken with him that
day. The man told him that he had spoken to his ex-girlfriend and explained
what they talked about. Prisoner C said he did not ask too many questions but
thought that the man seemed alright. He later walked behind the man to collect
their lunches from the servery. They both returned to their respective cells
which are locked over the lunch period. The man was alone as his cellmate B,
stayed at work.
90. Between 12.00pm and 12.30pm, Officer G completed a roll check of all the
prisoners on that spur. He said that he looked into the man’s cell and saw him
sitting watching the television, with his back to the door. Officer G said that he
did not notice anything untoward and the man raised no concerns with him
when he opened the cell observation flap. Officer G told the investigators that,
after completing the roll check, he left the prison as he had finished his shift.
91. Officer H told the investigators that he began his shift on houseblock three
either at 12.15pm or 1.30pm. He explained the procedure for unlocking
prisoners after lunch. At 1.50pm, staff start unlocking prisoners on the top
landing, at cell number 42, and then work their way round unlocking prisoners
who are listed for activities such as work, gym or visits. If a prisoner is not
listed for an activity, their cell stays locked.
92. The prisoners who are going to an activity gather on the middle landing, from
where they leave the spur, and staff secure their cells. The prisoners are
searched before they leave the house block and then make their way to their
designated places (called free flow) whilst staff wait to deal with any issues.
Officer H said that this would normally be concluded by 2.30pm, after which
staff would return to their spur and unlock the cleaners and other prisoners who
have appointments. All the other prisoners remain locked in their cells until the
evening association period, which begins at around 5.45pm.
93. Officer H and Officer F were responsible for carrying out the unlocking duties on
spur 1, houseblock three, but they did not unlock the man’s cell even though he
was a cleaner. Officer F said that she did not see the man after talking to him
earlier that morning. Both described the spur as busy in the afternoons and
they dealt with requests from prisoners.
18
94. Prisoner A left his cell at about 2.30pm after it was unlocked. He walked past
the man’s cell, which he noticed was closed. He went and talked to other
cleaners on the spur for a while and then walked past the man’s cell again, still
noticing it was locked. As he had not seen the man, he decided to lift the cell
observation flap to look inside. When he did so, Prisoner A initially thought that
the man was standing over his bed. He soon realised that he was hanging and
told Officer I who was sitting nearby to come to the cell.
95. Officer I immediately shouted for staff assistance, unlocked the man’s cell door
and went inside. He held the man up and waited for other staff to come to
assist by cutting the ligature. Officer I told the investigators that the man had
used the green bedding sheet as a ligature, which was tied around his neck.
The bedding had been put through the ceiling light fitting. The man was cold
and the officer saw no signs of life. Officer H had followed Officer I into the cell
and tried to take the sheet off the light. Prisoner B also came into the cell and
tried to help remove the bedding.
96. Officers E and Officer J responded and made their way to the man’s cell. When
Officer E went into the cell, he saw the two prisoners and Officer J lifting the
man and trying to loosen the ligature from around his neck. Officer E used his
anti-ligature knife to cut the ligature and the man was lowered to the floor.
Officer F had also responded to the call for staff and she too helped lower the
man to the ground. She then radioed the Control Room asking for an
ambulance to be called urgently. The alarm was raised at 2.45pm.
97. SO A arrived at the cell as the ligature was being cut. He ushered the prisoners
out of the cell and asked a member of staff to inform the house block nurse. He
then heard the general alarm over the radio net.
98. Officer H responded to the call for assistance. He had been in the middle
landing office dealing with a prisoner’s query. When he arrived at the cell, staff
were already inside dealing with the incident and so he began escorting other
prisoners away from the cell.
99. Nurse D had been walking along the middle landing on house block three when
staff shouted to her to come to the man’s cell. She told the investigators that
she quickly made her way to the cell. She examined the man who showed no
signs of life. However, she decided that cardiac compressions should be
carried out and called for further healthcare assistance.
100. Officer I had completed only three cycles of cardio pulmonary resuscitation
chest compressions (CPR) before Nurse E arrived and took over. He shouted
for a defibrillator machine to be brought to the cell.
101. The Physical Education Instructor (PEI) had heard the general alarm and
arrived at the cell. He was informed by staff that the incident was a medical
alarm rather than a general alarm. The two officers then continued to
administer CPR with Nurse D and the PEI (a trained first aider and instructor)
started to perform rescue breaths. The PEI also requested the defibrillator
machine (a life-saving machine that can detect electrical activity in the heart and
19
deliver an electric shock if appropriate) and was told that someone had already
gone to collect it. (Each wing has a defibrillator machine.)
102. Nurse E was in the medical treatment room when the general alarm was
broadcast over the radio. As she had the Hotel 99 emergency response radio,
it was her responsibility to respond to the alarm straightaway. Whilst she was
on her way to the cell, she was told by a prison officer that the defibrillator
machine was needed so she collected it with the oxygen and emergency bag.
On arrival at the cell, Nurse E gave the oxygen to the PEI and asked for more
oxygen and the ambu-bag to be collected. Nurse F also arrived at the cell just
before Nurse E.
103. The Developing Prison Service Manager A (DPSM) was the officer in charge of
the prison that day and he responded when the general alarm was broadcast
over the radio. He passed someone who was going to get the defibrillator
which told him that it was a medical alarm. The DPSM said that at some point it
was clarified over the radio that it was a medical alarm not a general one.
When the DPSM arrived, the PEI and Nurse D were giving CPR to the man.
The DPSM asked the staff and prisoners who were not required to leave the
cell.
104. The PEI operated the defibrillator. The machine advised that ‘no shock’ should
be given five times, and so the PEI and Nurse D continued carrying out chest
compressions and rescue breaths. A paramedic attended, which was recorded
as at 2.55pm, bringing another defibrillator machine which was attached to the
existing leads and pads. The prison doctor arrived at the same time. The
defibrillator advised ‘no shock’ a further four times and so CPR continued in
between each assessment. Three further paramedics also arrived within
minutes. CPR continued until 3.21pm when the doctor and the first paramedic
pronounced that the man had died.
After the man’s death
105. The duty governor arrived and activated the prison’s death in custody
contingency plans with the DPSM A. All the necessary agencies were informed
that there had been a death in custody.
106. The DPSM held a hot debrief meeting on the house block with staff involved in
the resuscitation of the man and invited the staff care and welfare team to
attend. He also met the prisoners who had helped the staff, using a Samaritan
and a Listener to offer support to them and to the man’s friends.
107. The man had named his next of kin as his mother who lived in Southampton.
The prison family liaison Officer, and DPSM B left Belmarsh at 5.50pm to make
their way to Southampton. They arrived at about 8.15pm and broke the news
to the man’s mother, stepfather and sister.
108. The man’s mother was offered a visit to the prison and given information about
what would happen next, including contacting the Coroner. The officers also
gave information about how the prison could assist with the cost of the funeral.
20
109. The man’s ex-girlfriend had telephoned the prison that evening and she spoke
to the duty governor. After her identity was confirmed, she was informed of the
man’s death.
110. The prison family liaison officer kept in contact with the man’s family about the
funeral arrangements. She visited the man’s mother and stepfather on 15 June
to return his personal possessions. The man’s mother later told the investigator
that some of his personal belongings were missing. My investigator spoke with
officers on the wings and was told that, as far as they were aware, all of his
property had been collected and passed to the prison’s FLO to return to his
family.
111. The man’s mother told the investigator that they had written to the man before
his death. The letter was returned from the prison through the post and marked
“PB Not here”. The prison family liaison officer apologised on behalf of the
prison service for this lack of sensitivity. The investigators made a number of
enquiries as to how this might have occurred but were unable to establish how
this had happened.
112. The investigator was given by the prison, a letter, a poem and a card
(addressed to the man’s children). The man had written these at some point
prior to his death. Within the contents of these documents he expresses his
love for his ex-girlfriend and his children. However no reference was made to
him harming himself.
113. The prison held a critical debrief meeting a few weeks after the man died and
the staff who attended said they benefited from the discussion.
21
ISSUES
114. The clinical review was conducted by the clinical reviewers and makes ten
recommendations. I note that it raises a number of concerns about prison
doctor B and some of the prison healthcare practices and policies. However,
these are not directly related to the circumstances of the man’s death and I do
not repeat them here.
115. The review also states that the care delivered to the man by the mental health
team at Belmarsh was prompt and comparable with what he might have
expected to receive in the community.
The man’s arrival at Belmarsh
116. The man received the normal reception and induction screening. However. the
initial health screen record, which should have been completed on 22March,
has not been provided for the investigator. There does not seem to be a record
of his past alcohol or substance misuse, his mental illness or having been on an
ACCT.
117. His ACCT document had been closed ten days before the man came to
Belmarsh and he was no longer considered to be at risk of harming himself.
The closed document did not travel with him to Belmarsh and only arrived eight
days afterwards. Reception staff made no enquiries with Pentonville as to
when the document was closed.
118. Prison Service Order 2700 mentions that, when transferring to another prison,
the safety and well being of prisoners require that any existing support and care
plans are maintained in the new environment. I appreciate that the ACCT
monitoring had ended 11 days before the man’s arrival at Belmarsh. However,
he had since appeared in court, been convicted and subsequently transferred
to Belmarsh to wait to be sentenced. These are factors which I think staff
should take into account when assessing the level of risk which a prisoner
might pose to himself.
119. That said, I was pleased to note that there was very good and prompt
communication between the mental health specialist in Belmarsh and relevant
colleagues in Pentonville about the man’s mental health, following the referral
made at reception.
120. The initial assessments, completed when a prisoner arrives at a prison, are vital
to ensuring that their immediate needs are met and determining how their care
and treatment should be delivered. If the assessments are not completed
properly, and relevant information is omitted or overlooked, subsequent
decisions will not be as informed or effective. Although these issues arose in
March, three months before the man took his life, and do not appear to directly
relate to his death, I make the following recommendation.
The Governor and Head of Healthcare should remind reception staff of the
importance of recording significant contact with prisoners. Where
22
reference to a prisoner’s previous risk has been identified, staff should
ensure that these records are obtained at the earliest opportunity.
Repeat prescribing system
121. The Belmarsh doctor repeatedly prescribed medication for the man but without
making his own assessment to ascertain whether his needs had changed. The
clinical reviewers noted that Belmarsh had no written repeat prescribing
procedure to ensure that patients taking long term medication are regularly
reviewed. To ensure that medication is prescribed appropriately and safely, it is
imperative that regular assessments are made.
The Head of Healthcare should identify safe systems for repeat
prescribing and to recall patients for tests and review.
Transferring medical information from paper to computer records
122. During May 2010, prisoner’s clinical records were transferred from paper to
computer. The PCT employed a data clerk to summarise the information
written by clinicians and enter the summary on to the computer records. The
data clerk’s name appears in place of the clinician’s name and the name of the
clinician making the original entries is not recorded. Neither the investigator nor
the clinical reviewer could find an audit trail as to whom conducted the
assessments. This created difficulties in ascertaining who had contact with the
man during his initial days in custody and should be interviewed for the
investigation.
The process of transferring the paper records to the computer is now complete,
and the omissions were identified many months ago. I therefore do not make a
recommendation to the Primary Care Trust but I am sure that, if the process is
ever repeated, they will want to ensure that it is undertaken correctly. The NHS
Greenwich PCT should ensure that IT data summarisers record the name of the
clinician who had made the entry in the manual record, so that the electronic
record indicates that the entry was made by the summariser.
Emergency response
123. The general alarm call was used to alert staff when the man was found
hanging. However, this did not indicate the nature of the emergency. Officer H
told the investigators that pressing the general alarm is a faster method of
summoning assistance, especially during free-flow, when there are a lot of radio
transmissions. He said that pressing the general alarm guarantees that the
Control Room are aware of an incident. Using a radio can be difficult as other
transmissions can interfere, which means that it can take longer for assistance
to arrive. Although the emergency medical response code, Hotel 99, was not
immediately used, I am satisfied that staff arrived to assist very quickly.
124. Since this investigation, the clinical reviewer has noted that new guidance has
been issued about raising alarms in emergencies which requires staff to
indicate the nature of the emergency. As the prison has already changed its
23
system following the man’s death, I do not make a further recommendation.
The emergency response was, in fact, well managed. The staff attended
promptly, had the necessary equipment which was all in good order, and did
everything they could to resuscitate the man.
Contact with the man’s next of kin
125. The man’s family have asked me to explain why his ex-girlfriend was told of his
death as well as themselves when they were the ones named as his next of kin.
The Prison Service Order 2710, entitled “Follow up To Deaths in Custody”,
gives guidance for family liaison officers. In paragraph 3.4 of chapter 4, it
states that “the Family Liaison Officer should be prepared to deal with different
sections of one family if necessary”. The PSO also gives a definition of “family”,
which includes the parents, children, spouses and partners, but also “others
who have had a direct and close relationship with the deceased”. I judge that
the man’s ex-girlfriend, as the mother of his children comes into this category,
and, once the prison confirmed her identity, I believe they were right to tell her
about his death.
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CONCLUSION
121 The man had previously attempted to take his own life while he was at
Pentonville. However, health assessments indicated that he had no severe
enduring mental illness and there was nothing to support a diagnosis of
schizophrenia or severe depression. The man did not show any signs of
depression or suicidal intent whilst he was at Belmarsh. He had gained
employment as a cleaner and did not come to the attention of staff in an
adverse way.
122 There was nothing to indicate that the man was at risk of self harm prior to his
suicide. It was evident that he regretted the offence which resulted in his
imprisonment and he appeared to want to positively address his offending
behaviour and substance misuse problems.
123 Even after the telephone call with his ex-girlfriend on the day he died, the man
did not express any suicidal thoughts to other prisoners or staff. Indeed, after
this telephone call, he saw several other prisoners, none of whom thought there
was a risk of the man harming himself. They said that he was frustrated and
worried about seeing his children but they did not think he was likely to harm
himself. The man’s conversation with his ex-girlfriend appears to have ended
on a positive note. Unfortunately, It is impossible to say why the man chose to
take his own life, and I have not found any evidence that his death could have
been predicted or prevented.
25
RECOMMENDATIONS
1 The Governor and Head of Healthcare should remind reception staff of the
importance of recording significant contact with prisoners. Where reference to
a prisoner’s previous risk has been identified, staff should ensure that these
records are obtained at the earliest opportunity.
The Prison Service has accepted this recommendation.
2 The Head of Healthcare should identify safe systems for repeat prescribing and
to recall patients for tests and review.
The Prison Service has accepted this recommendation.
26