Individual at Brixton

Circumstances surrounding the death of a man,
a prisoner at HMP Brixton, at Kings College Hospital,
London, in April 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2008
Final Report: The man Allen
This is the report of an investigation into the circumstances of the death of a man at
Kings College Hospital, London, on 28 April 2006, while a prisoner at HMP Brixton.
The man had been mentally ill for a number of years, and was located in the
healthcare centre at Brixton for the duration of his time there. On 7 March 2006, he
was found hanging in his cell. Cardio pulmonary resuscitation was carried out and
he was taken to hospital. The man did not return to prison and died seven and a half
weeks later. A post-mortem gave his cause of death as 1a) bronchopneumonia, 1b)
hypoxic brain injury and 1c) suspension. At the time of his death, the man was 33
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. The man’s family and solicitors raised a number of matters with one of my
Family Liaison Officers. I hope my investigation begins to offer answers to these
questions.
The investigation was led by my colleague. A clinical review was conducted a
General Practitioner, on behalf of Lambeth Primary Care Trust. I am grateful to the
General Practitioner for his review and careful consideration of the issues. I also
thank the Governor and staff at HMP Brixton for their co-operation with this
investigation. In particular, I am indebted to the establishment’s liaison officer.
This investigation has revealed a particularly troubling aspect of the man’s care.
Four hours prior to being found hanging, he had set fire to his right trouser leg and
suffered minor burns. He was placed on suicide and self-harm monitoring and
observed on an intermittent watch. The cell in which the man was located had dual
use, allowing it to be used as either an ordinary cell or a gated one. At the time, the
cell door was defective and the gate was used instead. Staff did not consider the
implications of placing a prisoner at risk of self-harm in a cell with an increased
number of ligature points. The man was found hanging from one of the gate’s bars.
I am critical of placing a prisoner deemed at risk, but not regarded as being in need
of constant supervision, in a gated cell. My report and the clinical review, contain a
significant number of recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2008
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CONTENTS
Summary 4
The Investigation Process 5
HMP Brixton 7
Key Findings 9
Issues Considered 18
Recommendations 26
Annexes 28
3
SUMMARY
On 28 September 2005, the man received a five year sentence for robbery. He had
been on remand for seven months. For much of the time, the man was in HMP
Pentonville, although he also moved to other establishments.
The man had a long psychiatric and offending history. At the beginning of November
2005, he was on ordinary location at Pentonville. However, his demeanour was
giving staff cause for concern. On 3 November, the consultant psychiatrist assessed
the man and requested his admission to the healthcare unit for observation.
However, Pentonville’s healthcare unit was undergoing refurbishment and the man
was therefore transferred to HMP Brixton on 4 November.
Upon reception at Brixton, the man was immediately placed in the healthcare centre
where he remained for the duration of his time at the prison. He proved very difficult
to manage during his first few days at Brixton, and following an attack on a member
of staff he was placed on a three man unlock. The man was assessed to be acutely
ill at the time and the consultant psychiatrist was unhappy about the move. He
immediately initiated procedures to have the man assessed and transferred to a
secure psychiatric hospital. However, the hospital’s visiting psychiatrist did not
agree with his assessment. The consultant psychiatrist sought a second opinion.
This again did not concur with the view of the consultant psychiatrist and the medical
team at Brixton.
The man was relatively stable at times, but for other periods was difficult to manage
and unpredictable. He was often non-compliant with his medication which in turn
impacted on his behaviour, and he was often placed on a three-man unlock.
On 6 March 2006, the man pulled his toilet off its hinges in his cell. He was
transferred to another cell, D1-01. This cell had dual use and could be used as
either an ordinary one or as a gated cell. At the time, the cell door was defective and
the gate was being used.
At 6.35pm on 7 March, the man set fire to his trousers leg after he had stuffed it with
newspaper. The fire was put out quickly with an extinguisher and the man was
moved upstairs to another cell, D2-01, whilst D1-01 was cleared up. However,
another prisoner was taken ill and staff needed cell D2-01 for this man. The man
was moved back to cell D1-01. Again, the gated door was in place.
Following the fire, the man was placed on a F2052SH (suicide/self-harm monitoring
arrangements). The decision was made to observe him intermittently, six times an
hour. At 10.20pm, the man was found hanging from the gate. Cardio pulmonary
resuscitation was conducted, initially by prison staff, and then by paramedics and
doctors from Kings College Hospital.
Having been taken to hospital, the man regained consciousness some days later
and was well enough to be moved to a ward. Sadly, he suffered a relapse and died
on 28 April.
4
THE INVESTIGATION PROCESS
1. My investigator conducted a preliminary visit to HMP Brixton on 10 May 2006
and visited the cell in the healthcare centre where the man was found hanging.
All the documentation was reviewed and a chronology of events established.
2. Notices were issued to staff and prisoners telling them of the investigation and
offering the opportunity to speak with my investigators. No one came forward
as a result. My investigators met with representatives of the local branch of the
Prison Officers’ Association (POA) and the chairman of the Independent
Monitoring Board (IMB).
3. Nineteen members of staff, both discipline and healthcare, were interviewed on
tape at Brixton by my investigator. On behalf of the Primary Health Trust, a
General Practitioner, undertook a clinical review of the healthcare provided for
the man at HMP Brixton. Joint interviews were conducted whenever possible.
4. During the initial visit to Brixton, my investigators asked nursing staff about
interviewing the prisoners who had been in the cells adjacent to the man. They
were told that the three prisoners in question had been transferred to outside
hospitals. This was confirmed by cross-referencing prison records.
5. On behalf of the London Area Manager of the Prison Service started an internal
investigation following the events of 7 March. This was in response to the
policy in operation at the London Area Office, which is to commission an inquiry
into any act of serious self-harm. At the onset of the investigation, the man was
still receiving ongoing treatment as an in-patient at hospital. The enquiry was
completed by the time of the man’s death. My investigators met with the
internal investigator and have received a copy of his report. I am most grateful
to him.
6. My investigator met with a detective inspector and detective sergeant of Brixton
CID on 10 May 2006 and liaised with them throughout the investigation. The
detective inspector provided my investigators with a copy of the police report.
7. One of my Family Liaison Officers made contact with the man’s family, offering
the opportunity to meet with the investigator. My investigator and family liaison
officer met with the man’s two sisters at the offices of the solicitors appointed by
the family.
8. Feedback from the investigation was provided to the Governor of Brixton on a
regular basis.
9. A draft version of this report was sent to the prison service. An action plan was
provided in response. The Prison Service indicated whether they accepted the
recommendations or not. The responses can be found under the
recommendations section of this report and have been reproduced verbatim.
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10. In addition, changes have been made to paragraphs 28 and 79 at the request
of the prison service. A number of requested changes to the clinical review
were not made as the author of the review, did not agree with them.
11. The man’s family and their solicitors were sent a copy of the draft version of this
report. They raised a number of matters, all of which were dealt with by way of
letter.
6
HMP BRIXTON
12. Brixton is a local prison, mainly serving the Inner London and Southwark Crown
Courts. It holds remand and convicted prisoners. There are four main
residential units and a healthcare centre (HCC). The man was located in the
HCC for the duration of his time at Brixton. At the time, the HCC (also known
as D wing) had capacity for 36 patients, 18 in single cells and 18 in shared
accommodation. Seven cells are fitted with metal toilets and sinks and
reinforced mattresses for the management of patients who exhibit disturbed
behaviour. Prisoners with physical health problems are also housed on D wing.
13. There are three levels on the HCC, the 1s, 2s and 3s. Level 1, which had four
single cells, was generally used for the most severely mentally ill. Those in the
3s were usually the most stable. There were no safer cells (cells with reduced
availability of ligature points) on the wing, although all the cell furniture was
secured to the ground. There were exposed bars on the cell windows.
14. When the man was on D wing there were two gated cells on level 1, D1-01 and
D1-02. These two cells had the dual function of being a normal cell or a gated
cell. They both have an ordinary cell door which can be locked back against
the cell wall when not in use, and a gate which can be locked. The gate then
operates as both a locked barrier as well as providing a means by which to
observe the occupant at all times if necessary. D1-01 was immediately to the
right at the bottom of the stairs.
15. HM Chief Inspector of Prisons, Ms Anne Owers, carried out an unannounced
full inspection of Brixton between 22 February and 3 March 2006. In her report
published in May 2006, Ms Owers described the healthcare arrangements in
the following terms:
‘… healthcare in-patient wing – supposedly a six-month temporary
solution – was still in operation two years later, in spite of its manifest
inadequacy. There was only a limited regime, too much reliance on
agency nurses, and the basement area, holding the most severely
mentally ill patients, was wholly unacceptable: with cold, concrete
floors and graffiti-covered walls. This was exacerbated by delays in
transferring patients to appropriate NHS mental health facilities: at the
time of the inspection, 11 prisoners were awaiting transfer, and at least
another five were awaiting assessment.’
16. Regarding the cells on the basement area (level 1), one of which the man
occupied the night he hanged himself, Ms Owers wrote: ‘the cells on the ground
floor of D wing should be condemned immediately’. Contemporaneous notes of
feedback given to the then Governor and all senior managers on 3 March
describe the unit as being ‘not fit for purpose’. On 24 April 2006, On 15 May
2006, the Governor took the cells out of use. Two cells on level 2 of D wing
were modified to be used as gated cells when needed.
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17. In her report, Ms Owers also recommended that: ‘A purpose-built in-patient
facility should be provided as a matter of urgency. Mental health staff should
be consulted about the new building to ensure that it is fit for purpose.’
18. Including the man, there were five deaths at Brixton during 2006, all of which
have been investigated by my office. These are all still awaiting inquests. Two
are regarded as deaths by natural causes and three were apparently self-
inflicted. Of those who died apparently at their own hand, the man was the only
one to have been located in the HCC. Reviewing my other investigations, there
appear to be no issues of specific relevance to the circumstances of the man’s
death.
19. Lambeth Primary Care Trust became formally responsible for the healthcare
provision at HMP Brixton in October 2005. The prison health partnership board
has responsibility for monitoring the delivery of services under the clinical
governance arrangements.
20. On 21 August 2006, Brixton introduced the Assessment, Care in Custody and
Teamwork (ACCT) system for monitoring and supporting those at risk of self-
harm and suicide. This replaced the F2052SH.
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KEY FINDINGS
21. The man was seen for a psychiatric review on 3 November 2005. This
indicated that he was having a relapse of his psychotic illness and that he
needed to be moved to the healthcare centre for further assessment. It was
also recorded that the consultant psychiatrist had been approached by a fellow
prisoner (who said he was a friend of the man’s) who was very concerned
about the man’s recent deterioration in his mental health.
22. On 4 November, following the closure of the healthcare centre at Pentonville,
the man transferred to Brixton. A note in his medical record, dated 3
November, said that the man had been accepted by principal officer on D wing,
and a Consultant Forensic Psychiatrist at Brixton.
23. The consultant psychiatrist reviewed the man’s history following his arrival. He
recorded that the transfer was not discussed or agreed with him and that
transfer ‘at this stage of his treatment is highly inappropriate’. The consultant
psychiatrist referred the man to a local NHS Mental Hospital, for assessment
and with a view to his admission as an in-patient. This was followed on 12
November by a letter from the staff nurse to highlight the impact that the man
was having on the nursing staff.
24. The man was admitted to D wing. His first days at Brixton were difficult. He
was said to have been laughing inappropriately, being constantly noisy
throughout the night, and refusing his medication. His personal hygiene was
also poor, and the man was noted to have urinated and defecated
inappropriately on 8 November. Following an assessment on the same day,
the consultant psychiatrist repeated his criticism of the transfer, saying that ‘it
happened without clinical discussion’ and that he ‘would not have accepted him
for transfer had this been discussed in advance’. It is unclear how the
discrepancy between the account given by the consultant psychiatrist and the
written notes referring to the principal officer on D wing occurred.
25. At around 6.05pm on 8 November, the man attacked three members of staff on
the stairs of D wing and had to be physically restrained. Immediately prior to
this, he had been ‘howling’ during the association period and staff had
attempted unsuccessfully to calm him down. The man was subsequently
placed on a three man unlock, meaning that three members of staff had to be
present each time his cell was opened. This had the effect of restricting the
amount of time he was able to take part in out of cell activities.
26. The man’s behaviour continued to deteriorate and he was refusing his
medication. During the afternoon of 12 November, he flooded his cell (D1-03)
with water and excrement. As a result, a decision was made to forcibly
medicate him, under common law, and the man moved cells to D1-04.
27. During the evening of 19 November, the man moved cells to D1-01 after a ‘fire
incident’ in D1-03. There are no further details given in the records. By 21
November, he had improved a little, although was still refusing to take his
9
medication and a decision was made to try removing the three man unlock
during an exercise period. This trial went well.
28. At around 9.40pm that evening, however, the man flooded his cell after
demanding a phone call and to see the duty governor. He spoke to a Listener
(a prisoner who has been trained by the Samaritans to offer support) later that
evening, and was recorded to be more settled through the night.
29. The man moved cells from D1-01 to D1-02 on 25 November. The reason for
this move is not recorded. On the following afternoon, the three man unlock
was fully rescinded as the man’s behaviour had become more settled in the
preceding days. The following conditions were imposed:
(cid:127) The man should comply with his medication.
(cid:127) He should show settled behaviour, without resorting to aggression.
(cid:127) He should make an effort to communicate with staff.
33. Two hours later, the three man unlock was reinstated. The man had been
‘howling’ and laughing loudly in his cell, and had been accusing staff of holding
him illegally. According to an entry in the medical record, staff was unable to
communicate with the man ‘in any meaningful way’.
34. The man moved back to cell D1-01 on 1 December. He had become more
settled, although was still prone to shouting during the night. He was now
complying with his medication. On 2 December, he was assessed by a
Consultant in Forensic Psychiatry from the local mental hospital. The consultant
psychiatrist wrote in the man’s Medical Record: ‘I judge his PD (personality
disorder) as untreatable’ and said that she was ‘very reluctant to consider him
for hospital transfer’. She confirmed this opinion in a letter to the consultant
psychiatrist at the prison on 15 December.
35. The man’s behaviour continued to be unpredictable throughout December.
Although he was often noted to be quiet and settled, there were also a number
of occasions in which he was reported to be shouting and banging throughout
the night or asking staff to let him go home. In particular, on 10 December he
threatened to ‘cut up’ members of staff. On 22 December, he was moved from
cell D1-01. He flooded his cell on both 24 and 25 December.
36. The consultant psychiatrist at the prison did not agree with the consultant
psychiatrist from the local mental hospital’s conclusions in her assessment of
the man on 2 December. At the management round of 6 December, he
remarked that he considered the view that the man was untreatable to be
unacceptable. After a review on 3 January 2006 at which he noted that the man
had improved considerably, the consultant psychiatrist from the prison referred
the man to the local mental hospital for a second opinion.
37. The man continued to improve through January, and on 10 January it was
decided again to take him off the three man unlock. He was relocated to D3-08
on 23 January. At a review the following day, the consultant psychiatrist noted
10
that the man was ‘generally compliant and settled, but easily aroused and
agitated’.
38. At a ward round on 27 January, the man was noted to be refusing to take
Clopixol (an anti-psychotic drug) on account of the side effects. The consultant
psychiatrist recorded that the man was engaging and polite at interview, and
displaying no current psychotic symptoms. The consultant psychiatrist
considered that the man ‘clearly has the capacity to make decisions re treatment
at present’, and that he was unable to opt for compulsory treatment. He
therefore agreed to discontinue Clopixol and start the man on Aripiprazole
(another anti-psychotic drug) as an alternative.
39. The man remained settled over the next week. On 30 January, he spoke to a
Samaritan on the telephone, and on 1 February he was seen by a Listener. On
7 February, the man complained of hearing voices especially at night. He said
that the voices were derogatory but did not issue commands, and that he felt
scared. The man said that he had no thoughts of self-harm or suicide at this
time. By 10 February, the man said that he was hearing voices all day. He
asked for an increase in Aripiprazole to counter this. This was agreed by the
senior house officer in psychiatry.
40. The man again settled for about a week. At around 11.30pm on the night of 18
February, he asked to see a Listener. This request was refused by the
healthcare officer as the man had refused to go back to his cell earlier that
evening when told to do so. The healthcare officer recorded that he was ‘most
reluctant to put my colleagues at risk in a potentially dangerous situation’.
41. On 20 February a second consultant psychiatrist from the local mental hospital
assessed the man. The second consultant psychiatrist acknowledged the man’s
complaints of hearing voices, but did not consider that he had demonstrated
behavioural disturbance. He concluded that the man did not require transfer to
hospital.
42. During the course of the next week, the man began to display signs of paranoia.
On 22 February, he accused two members of healthcare staff of taking bribes to
keep him in prison. An entry in his medical record on the same day noted that
the man had shown a ‘rapid decline in mental health state in the last 24 hours’
and that ‘there is clear evidence that he is relapsing’. The man was later
examined by the senior house officer in psychology. During the examination, he
repeated his paranoid thoughts but expressed no thoughts of suicide or self-
harm. After a lengthy conversation, the senior house officer persuaded the man
to take his medication.
43. On 23 February, the man was noted to be ‘very subdued’ and ‘very paranoid’.
He was described as ‘still very psychotic’ on 26 February, and this was
attributed to his depot (an injection of drugs) being stopped. Telephone records
indicate that the man made his last phone call on 27 February.
44. The man was assessed by the specialist registrar in psychiatry at Brixton, on 28
February. The specialist registrar described the man as ‘paranoid,
11
argumentative and with persecutory delusions’. The man listed to the specialist
registrar up to 50 people whom he believed were conspiring to keep him in
prison. He again reported hearing voices, but said that they were better. The
specialist registrar decided to write the man up for depot Clopixol. This was
supported by the consultant psychiatrist at the ward round that afternoon. The
consultant psychiatrist agreed that the man was ‘clearly psychotic’. The
management round notes for that day record:
“Paranoid and expressing persecutory ideas about staff. Thinks staff
are working with the police to keep him here unlawfully. Thinks the
judge and solicitors are fake. Action: re-start his depot and encourage
compliance.”
45. The man continued to appear psychotic and challenging to staff over the next
few days. On 4 and 5 March, however, he was noted to be settled and pleasant
and had been engaging in cleaning duties with enthusiasm. On 5 March, it was
noted that the man ‘appears to be mentally stable’.
46. At around 12.30pm on 6 March, the man lifted his cell toilet from its hinge. The
nurse in charge of D wing described the man as being ‘very paranoid’. Given
the state of the cell, the man was not able to remain there and was moved to cell
D1-01 which was used with the gate in place. In her interview, the nurse said
that the man’s behaviour probably justified him being placed in that cell, but she
could not recall whether there were any other cells available.
47. In response to being asked about how cell D1-01 was being used, the nurse
said:
‘I don’t think it was condemned at that stage, it still, I mean I remember
the door wasn’t, there were still problems with the door. But it still had
a, I think it still had a gate. But it wasn’t, at the time it wasn’t
condemned. At the time, I think that was only as a last resort, really ...
The gate was, I think, was in use.’
48. It was noted in his medical record that the man ‘remains paranoid at times and
challenging’. Later that afternoon, the man was assessed by the senior house
officer. He complained of anxiety and insomnia, and the senior house officer
thought that he looked very distressed. The man said that he had no thoughts
of self-harm at the time. At around 6.30pm, he was seen by the staff nurse and
asked to have some talcum powder on his head. At interview, the staff nurse
said that he took this as an indication that the man was still quite disturbed or
unwell. The record of cell bells for the day shows that the man pressed the cell
bell at 2.56 pm, 3.39 pm, 8.23 pm, and 11.36 pm. All were answered fairly
promptly.
7 March
49. The man then had an unsettled night. At midnight, he was demanding
medication and shouting at the top of his voice. He was given Haloperidol 10mg
(an anti-psychotic) at this time. At around 3.30am, he demanded to be released
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with immediate effect. An entry in his medical record at the end of the night said
that he had been pressing his cell bell constantly and demanding to be taken to
the prison reception area to be released. Records show he pressed his bell at
3.41am, 4.03am, 5.04am, 6.57am, and 7.56 am. On the whole, these were
answered promptly, except the last one which appeared to have been answered
after 40 minutes.
50. The man was one of 20 prisoners seen on a ward round at around 3.00pm on 7
March. In his written assessment following the round, the senior house nurse
noted that the man was on three man unlock. The documentation does not give
any reason for this, but the man’s actions the previous day may have prompted
staff to place him on this restriction. His status would have been reviewed after
24 hours. The man was noted to be continuing to express paranoid delusions
about particular officers and continuously demanding his release. The senior
house nurse recorded the view of the Forensic Liaison Nurse that ‘he should not
continue in the prison and needs to be transferred out’. A decision was made to
‘increase the man’s depot, and that he should remain on D wing’. The nursing
notes record, ‘appears to be deteriorating. Thinks staff are taking bribes to keep
him incarcerated. Paranoid about some staff.’
51. In interview, the staff nurse recalled seeing the man standing at the gate of cell
D1-01 when he returned from the management round. He recalled the man
asking about having a shower and whether he was going to be on a three man
unlock because of ‘what he did’.
52. The man rang his cell bell on a number of occasions during the afternoon of 7
March. An entry in his medical record at 4.40pm said that the man:
‘… appeared very restless and agitated due to the fact that he has
been placed on a three man unlock. Most of his statements are
incongruent and has been very paranoid about staff. Has been eating
and drinking well but was refused association due to a limited number
of staff on the wing.’
53. A nurse recalled speaking with the man that afternoon. She said that the man
had wanted to come out to collect his dinner which she allowed him to do. She
said that at this time he was calm.
54. She returned to the cell a little while later and noticed that the man was putting
his fingers in his ears. The nurse asked the man why he was doing this and he
said that he could hear voices and wanted to block them out. The nurse was
worried about the man and at around 6.30pm decided to open a F2052SH (the
form used at the time by the Prison Service to monitor prisoners deemed at risk
of suicide or self-harm). The nurse wrote in the nursing assessment section of
the form: “Complained of hearing voices. Requested help, needs more
medication. Had fingers in his ears to block out voices. Frightened and
anxious.” She placed the man on ‘Intermittent Supervision’ (IS), meaning that
he would be observed at random intervals averaging once every ten minutes.
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55. At around 6.35pm, whilst the nurse was completing the F2052SH, the man set
fire to the right leg of his trousers after stuffing both legs with newspaper. He
was discovered by a healthcare assistant after he heard shouts and went down
to the 1s. He saw smoke coming out of the man’s cell and immediately called to
a second nurse, who was in the staff office on level two, for assistance. The
second nurse collected the fire extinguisher from a third nurse and ran down to
the cell. The healthcare assistant opened the man’s cell, and the second nurse
entered and extinguished the fire.
56. The man was then moved to cell D2-01, and a doctor was called. A doctor from
reception attended and assessed the man. He concluded that the burns were
superficial and red, but not blistered. He asked the nursing staff to apply
Flamazine cream (an antibiotic used to treat and prevent infections at the site of
burns). He also prescribed a course of erythromycin (an oral antibiotic) to be
used if necessary.
57. In interview, the reception doctor recalled that the man had said that he had
accidentally set fire to his leg. He said that he was not made aware of the man
having stuffed newspaper down his trousers. At the time, the reception doctor
was not asked to make an assessment of the man in terms of his mental health
by any member of healthcare staff. However, in interview he recalled the man
as:
“… lucid and the fact that he could answer my questions, and he wasn’t
being held down, he wasn’t making things up, there was no sort of
delusional quality to his speech … I made an assessment that he
wasn’t delusional at the time when I saw him, he didn’t seem
particularly agitated, because obviously I would definitely have
commented on that.”
58. The third nurse completed form F213SH (a form used to describe incidents of
self-harm or attempted suicide), and the reception doctor countersigned it. The
nurse remembered that the man kept on saying ‘I am sorry’.
59. The duty governor was called to healthcare. In interview, he said that he
established that a F2052SH was opened and then left D wing. He did not speak
directly to the man.
60. The healthcare assistant remained with the man until around 8.00pm. The man
was calm and very apologetic during this time and the healthcare assistant
provided reassurance. At about 8.00pm, the man was moved back to cell D1-01
as another prisoner who was unwell needed to be in D2-01 due to its proximity
to the wing office. In interview, the nurse said that the man had asked to go
back to cell D1-01. Intermittent supervision began at this time (six checks an
hour), and D1-01 was again used as a gated cell.
61. The third nurse made entries in the man’s supervision record at ten minute
intervals from 8.00pm until 8.50pm inclusive. Three observations record
‘standing at gate’. The entry at 8.20pm says ‘asked for a light’, and at 8.30pm it
says ‘smoking stood at gate’.
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62. At around 8.45pm, the night staff took over on D wing. The nurse in-charge,
with callsign Hotel 3, and the emergency response nurse. They were based on
D wing, but would respond to medical emergencies and other healthcare duties
throughout the prison, which often took them off the wing for long periods of
time. A prison officer and the healthcare assistant were stationed on D wing
throughout the night.
63. The staffing levels are detailed in the Healthcare Centre Operating Procedures.
At night, the optimum staffing levels for D wing are one desk officer, three
nurses and one healthcare assistant. On 7 March, there were only four staff.
The reason for this is not known.
64. The night staff received a handover at the start of their shift. At interview, the
nurse in charge said that he was told about the fire incident at the handover and
that the man was now on intermittent observation and settled. He said that the
night staff were told that if the man became restless they should put him onto
constant supervision.
65. In interview, the emergency response nurse recalled being told about the fire
incident and that if necessary he should be put on constant supervision. After
the handover, she recalled speaking to the man as she walked passed D1-01 on
her way to the treatment hatch. He was polite and calm and different from how
she had seen him the night before. Some time after 9.00pm, the nurse in
charge and emergency response nurse both left the D wing. The emergency
response nurse said that she left the wing in response to a call for Hotel 6 and
that the nurse in charge went with her.
66. The nurse remembered speaking with the man as she was leaving at the end of
her shift some time after 9.00 pm. She said that she put her hand on the rail
and he took his hand and put it over hers: “…and he was saying that he was
very sorry. I said to him ‘stop apologising’, I like it that he is well and I will see
him tomorrow and he said ‘alright’.”
67. The prison officer wrote an entry in the F2052SH at 9.00pm: ‘Speaking to [the
man] and he was requesting diazepam. (Told he will see the doctor am), given a
cigarette and no self-harm observed.’ (In interview, the prison officer was asked
whether he was sure that it was diazepam and not lorazepam that the man
asked for. Lorazepam was one of the medications that the man was on. The
prison officer said it could have been lorazepam.)
68. The prison officer spoke to the man about the fire, and said that he would put
him down to see the doctor in the morning. He also gave the man a cigarette
when he asked for one. The nurse in charge also recalled the man requesting
diazepam at this time. He told the man that he could not give him diazepam as
he was not written up for it, but that he would put him down to see the doctor in
the morning.
69. The healthcare assistant carried out the intermittent observations on the man
from 9.00pm onwards. At each interval through to 10.20pm inclusive, he was
15
recorded as either ‘standing at gate’ or ‘sitting on bed’. The man also pressed
his cell bell three times (at 9.21pm, 9.32pm and 9.36pm). It is not clear what the
man wanted on these occasions, although the healthcare assistant recalled him
asking if the nurse would be working the next day.
70. When making his check on the man at 10.10pm, the healthcare assistant asked
him if he was all right and whether he would like a drink. The man nodded and
said that he did not want a drink. He then sat down on his bed, silently. The
healthcare assistant carried on with his rounds.
71. Around ten minutes later, at approximately 10.20pm, the healthcare assistant
returned to the man’s landing to make his next check. At interview, the
healthcare assistant said that, when he reached the foot of the stairs, the man
appeared to be standing and resting against the bars. He therefore made the
entry ‘standing at the gate’ in the record. However, he saw no movement from
the man and therefore went to have a closer look at him. The healthcare
assistant then saw that the man had made a thin ligature from a strip of bedding
and had tied it around his neck and to the bars of his cell. At this time in the
evening, the light on the wing landing was out and the place was quite dark.
72. The healthcare assistant immediately called the prison officer for assistance. He
ran downstairs from the office, opened the cell using the key from his sealed
pouch, and cut the ligature. The prison officer then pulled the man onto the
landing, as the cell was small and cramped, and made an urgent call over the
radio. The incident log shows that a ‘code 1 in D wing’ was made at 10.20 pm.
(Code1 is an emergency call for assistance and indicates a life-threatening
situation, such as a hanging, in which the person concerned is unresponsive.)
The healthcare assistant determined that the man was not breathing and found
a faint pulse. He then started cardiopulmonary resuscitation (CPR), joined by
the prison officer after he had made the emergency call.
73. Shortly afterwards, a temporary senior officer arrived and, having assessed the
situation, went to the up to healthcare office which was within site of the man.
From there, he telephoned the communications room to request an ambulance.
The temporary senior officer was the Orderly Officer (also known as Oscar 1),
meaning that he was in charge of the prison during the night. He then took over
from the prison officer who was doing chest compressions. Around five minutes
later, the nurse in charge and emergency response nurse arrived back and took
over CPR. Staff did not attempt to use the emergency resuscitation equipment
which was in a locked cupboard a few feet away from where they were working
on the man.
74. At 10.28pm, an ambulance arrived at the prison. By coincidence, one had been
passing when the call was made to the emergency services. Unusually, the
gate was staffed as workmen were coming in and out of the prison. This
allowed the ambulance and doctors to be swiftly processed through the gate and
into the prison. Another paramedic arrived at 10.32 pm. The assistant to the
Orderly Officer, met the ambulance at the main gate and escorted the
paramedics to D wing, where they took over CPR.
16
75. Another ambulance and a doctor from Kings College Hospital attended at 10.40
pm. The doctor opened the man’s chest to apply direct treatment to the heart
and the man was then taken to hospital by ambulance. Two prison staff
accompanied him. The officer escort was later reduced to one and this
remained the case up to the man’s death. There was no hot-debrief following
the man being taken to hospital and it would seem that no debrief involving all
staff members took place.
76. The man’s next of kin as recorded on the Local Inmate Data System (LIDS), a
prison-based computer system for recording prisoners’ details, were his parents.
An address but no telephone number was provided. The duty governor, who
had been called to the prison at around 10.30pm by temporary senior officer,
tried to get a telephone number for the man’s next of kin through directory
enquiries but found that their number was ex-directory. He therefore asked the
police to visit the man’s parents to tell them what had happened. In interview,
the duty governor did not recall giving the police a direct number for the prison
so that the family could contact anyone. The man’s parents visited him at King’s
College Hospital at around 2.00 am on 8 March.
77. On 13 March, the man’s family wrote to the prison to complain that no
representative had contacted them to explain what had happened to the man on
the evening of 7 March. By chance, they had discovered the burn injuries on the
man’s leg after a hospital blanket had slipped off and they had caught sight of
them. In response, Brixton’s chaplain, contacted the family and in the company
of the duty governor visited the family at the hospital.
78. The man regained consciousness and was moved from intensive care to a ward.
In early April, he was shown to be making progress. However, the man’s
condition deteriorated and he died on 28 April 2006. Staff from the hospital
contacted the family to tell them of the man’s death.
79. The chaplain later made contact with the man’s family, and he and the
Governor, visited the family a few days after the man’s death. The man’s family
said that they had been told that the prison would pay for the full cost of the
man’s funeral. The prison later denied this and the family delayed the funeral
until the matter was resolved. Eventually, the Governor agreed to pay the
funeral expenses in full.
17
ISSUES CONSIDERED
Supervision
80. The man had an extensive psychiatric history. When he arrived at Brixton, he
was very unwell and his behaviour clearly disturbed. Over the following five
months, he was intermittently stable. The clinical reviewer wrote that lack of
compliance with his medication led to repeated relapses in the man’s mental
state.
81. The clinical reviewer also highlighted the context within which care was being
given to the man:
“The hospital wing of Brixton Prison, D Wing, is not a hospital. It is a
run-down building, overcrowded, noisy and with limited facilities. D-
Wing was, at the time of these events, holding large numbers of very
mentally disturbed prisoners who would undoubtedly have been in-
patients in psychiatric hospitals, had they not been in prison. The
staffing levels in psychiatric hospital units would have been significantly
higher than was possible in HMP Brixton.”
82. As noted earlier, HM Chief Inspector of Prisons, Ms Anne Owers, who undertook
an unannounced inspection of Brixton just days before the man hanged himself
found D wing to be seriously inadequate.
83. At 6.35 pm on 7 March, the man set fire to his right leg after stuffing his trousers
with newspapers. A F2052SH suicide/self-harm monitoring form was opened
and the man was placed on intermittent supervision (IS) to be observed six
times an hour. The other option for staff was to place the man on constant
supervision (CS). At the night shift handover, staff were told to place the man
on CS should his behaviour worsen.
84. After any act of self-harm, a prisoner must become subject to suicide/self-harm
monitoring. The level of supervision is always a matter of judgement. Brixton’s
Suicide and Self-Harm Policy describes the different levels of observation and
the type of behaviour displayed:
Constant supervision:
(cid:127) Actively suicidal, especially if no close relationships
established with others
(cid:127) Unpredictable psychotic states
(cid:127) Recent direct self-harm with apparent suicidal intent
Intermittent supervision:
(cid:127) Not considered actively suicidal at present but still a high risk of
suicide
(cid:127) Recent self-harm with some suicidal intent
18
My investigators obtained records regarding the number of suicide/self-harm
watches in D wing. In January 2006, there were 18 occasions of constant
supervision (each occasion = 24 hours x 1 prisoner) and 103 of intermittent
supervision. In February, there were four and 123 respectively, and for March,
12 and 170 respectively. This would suggest that staff will place prisoners on
constant supervision if they perceive them to warrant this level of observation.
85. The clinical reviewer takes the view that:
”… given the evidence of instability in the man’s mental state over the
previous few days, the clear concern of Charge Nurse in opening the
F2052SH, and the episode of setting fire to himself, I think that the
decision to opt for IS was incorrect.”
He continues:
“...although a number of witnesses have commented on how calm,
polite and communicative the man was, there was evidence of further
worrying signs, such as the man pressing his emergency bell on three
occasions between 9.21 pm and 9.36 pm. At 9.00pm, shortly after
coming on duty, the prison officer noted in the F2052SH that the man
was requesting further sedative medication. Given the overall
situation, a decision might have been made to change the status of
observation from IS to CS.”
86. On balance, I am not myself minded to be critical of judgements made by staff.
Staff made a decision based on their experience, and their knowledge of the
man. After the fire, different members of staff spoke with the man and the
healthcare officer spent a considerable length of time with him. They were all of
the opinion that the man was apologetic and lucid. The man did ring his bell on
a number of occasions, but this in itself was not unusual behaviour for him.
87. However, I do not believe that a prisoner who has been deemed to be at risk of
suicide or self-harm should have been located in a gated cell unless he was
subject to constant observation. A cell closed by a gate provides a greatly
increased number of potential ligature points. In trying to ascertain why staff
appeared not to have considered the danger of placing an at risk prisoner in a
gated cell, a confused picture has emerged.
Use of gated cell
88. Cell D1-01, and its neighbouring cell, D1-02, both had dual use. This allowed
them to be used as an ordinary cell and as a gated one. By locking back the
door against the internal cell wall, the external gate could be locked and used as
both a barrier and to observe the occupant. The cell door to D1-01 was very
difficult to open, requiring significant force.
89. It is a requirement that all cells are checked on a daily basis (these are known
as Accommodation & Fabric Checks), and any problems reported to the local
contractor to be fixed. On D wing, records show that any problems were either
19
recorded in a ‘small repairs book’ or on the daily briefing sheet. It is not known
why there were two methods of recording and whether they worked
independently of each other. However, both show that the problem with the
door of cell D1-01 was recorded.
90. The daily recording sheets show that on 5, 6 and 7 March, the problem was
passed onto Mowlem, the local civilian contractor responsible for repairs. The
‘small repairs book’ indicates that D1-01’s door had been problematic for a
considerable time. It is noted on 30 June 2005, 7 July, 14 July, 26 August, 27
October and then again on 7 Feb 2006. The record indicates that each time the
problem of ‘D1-01 cell door’ was noted an entry that ‘works’ had been informed
would follow.
91. Records provided by Mowlem (since renamed Carillon) show that on 27 October
2005 a docket was raised and details given as ‘damaged lock cell door stop
faulty’. The docket shows that someone attended on 27 October and wrote
’done’ on the docket. Another docket was raised on 3 January 2006, and the
repair was recorded as ‘unspecified cell door stiff, may need greasing’. A
worker attended on 4 January and had written ’completed’ on the docket. On 7
February, another docket marked urgent was raised. A locksmith attended the
same day and ‘found the lock and gate hinges to be stiff but operational’.
92. The ‘occupancy history’ record of cell D1-01 was reviewed by my investigators.
The record starts on 31 March 2005 with a prisoner being placed in the cell.
There is no corresponding departure date but other records show that he left the
prison on 7 April 2005. The cell then appears to have been empty until 26
October. After that, it was in almost constant use until March 2006. The man
was located in D1-01 from 19-25 November and 1-22 December.
93. In interview Head of Healthcare, said:
”… there were problems with the door on D1-01 and that had been
reported over quite a lengthy period, and it periodically worked and
periodically didn’t. Sometimes the Works had been contacted and
somebody has come over and put oil on the hinge or lifted it slightly
because it was sticking, you couldn’t use it safely. So sometimes it
was used with the door open but a gate only.”
I take the head of healthcare’s remarks as confirmation that the cell was being
used as a normal cell but with the door open and the gate used as a barrier.
94. The impression I gain is of a problematic cell door which the repair team felt was
operational, but the staff in D wing considered to be defective. Under such
circumstances, I would have expected a decision to have been made about
whether to take D1-01 out of commission until the door was fixed. Staff could
have continued to use it as and when a gated cell was required. However, this
did not happen and cell D1-01 continued to be used as an ordinary cell but with
a gate.
20
95. The head of healthcare was asked in interview about instructions regarding the
use of gated cells. He said that he was not aware of any policy about the use of
gated cells. He was unable to recall having any discussions with his staff or
other senior staff about the appropriateness of using gated cells other than for
constant supervision. The head of healthcare said that the man had been in the
cell intermittently, for a few days at a time. He said staff felt it was more
beneficial to the man’s health as he had an increased level of contact with other
prisoners such as the cleaners, and he could interact with staff more easily than
through a small hatch.
96. Prison Service Order 2700, Suicide and self-harm prevention, provides
instructions and mandatory requirements and came into effect in January 2003.
One of the requirements of PSO 2700 is that each establishment must have its
own local suicide and self-harm prevention strategy. The strategy must include
reference to a number of conditions including ‘when to use the establishment’s
specialist designations eg safer cells’. Brixton’s Suicide and Self-Harm
Prevention Local Operating Practice (effective from November 2005) makes no
reference to safer cells, constant supervision, or the use of gated cells except to
draw the reader’s attention to PSO 2700 Chapter Four for ‘segregation and
accommodation of at risk prisoners’. Brixton’s Suicide and Self-Harm
Prevention Policy does not make reference to the use of ‘safer cells’.
97. I am concerned that no action was taken regarding the continued use of cell D1-
01, a gated cell being used as an ordinary cell. Chapter 4 of PSO 2700,
Managing prisoners identified at-risk to self, discusses the different types of
accommodation for at-risk prisoners. The reader is advised to refer to safer cell
protocols in section 4 of the guidance document accompanying the PSO.
According to the protocol, D1-01 would be classified as a dual use gated cell.
(Dual use is achieved by detailing a standard cell door and gate to operate
separately.) The protocol states that:
’… gated cells are used where a prisoner requires constant
observation. They enable a severely distressed/at risk prisoner to
receive individual support designed to reduce their heightened
emotions. A person should remain in a gated cell for the shortest time
possible.’
98. The protocol also says, ‘gated cells should not be used to house prisoners
without constant observation when the gate is in place’. This is described as
‘prohibited usage’. Clearly, D1-01 was being used contrary to the protocol.
99. The man was moved from his cell after he pulled the toilet off the wall on 6
March. The healthcare assistant, who was the first to arrive when the man set
fire to himself the next day, recalled that the gate was in place and that he saw
the smoke and flames through it. The second nurse, who got the fire
extinguisher, says the door was in place. The self-harm/suicide form (F213SH),
which is used to record any acts of self-harm, described the man as being in a
gated cell. On balance, the evidence would suggest that when the man was
placed in cell D1-01 the gate was in use.
21
100. My investigator and clinical reviewer discussed with the head of healthcare
whether it could have been possible that the man was placed back in to cell D1-
01 because there was no other available space on D wing. The head of
healthcare produced a written breakdown of the occupancy levels for D wing
which suggests that this was not the case.
2 March Unlock 30 (2 cell risk, 2 repair, 1 decorate) D1-01 not occupied
3 March Unlock 30 (2 cell risk, 2 repair, 1 decorate) D1-01 not occupied
4 March Unlock 30 (2 cell risk, 3 repair) D1-01 not occupied
5 March Unlock 30 (1 cell risk, 4 repair) D1-01 not occupied
6 March Unlock 30 (1 cell risk, 3 repair, 1 decorate) D1-01 occupied by the
man
101. The balance of evidence suggests that D1-01 had been used on many
occasions as a gated cell, including the man’s previous occupancy. Indeed in
the man’s case, at least, being in cell D1-01 with the gate in place was seen as
a positive thing. The lack of other cells does not seem to have been a factor in
the accounts given by all staff. My investigators were left with the impression
that staff had got used to using D1-01, and on this occasion did not consider the
implications of the gate in terms of providing ligature points.
The Governor should urgently review the local Suicide and Self-Harm policy to
reflect the use of gated cells, including their prohibited use.
Should the man have had a lighter?
102. In interview, the Healthcare Manger, the head of healthcare, said that all
prisoners are risk assessed with regard to in-cell possessions. The man was a
smoker who had in his possession a lighter which he subsequently used to set
fire to himself. However, staff had not deemed the man to be at risk with a
lighter and, except with the certain vision of hindsight, I have found no evidence
to indicate that this assessment was unreasonable at the time it was made.
The transfer from HMP Pentonville
103. Due to the temporary closure of the healthcare department at HMP Pentonville,
other London prisons were asked to co-operate with any transfers. The transfer
of prisoners between prisons is routine and is often done in circumstances
beyond the control of staff, for example, following a court appearance.
However, in the case of a mentally ill prisoner this should not occur unless there
has been a discussion between clinical teams from both the departing and the
receiving prison. In the man’s case, this does not seem to have taken place in
spite of the fact that the move was planned. When he arrived, staff at Brixton
immediately felt that in the light of his poor health he should never have been
transferred.
104. The clinical reviewer viewed the transfer of the man as highly inappropriate
given how unwell he was at that stage. As the man had been in Pentonville
since May 2005, a sudden and unplanned transfer could have resulted in a
further deterioration in his mental state. However, given that the healthcare
22
centre at Pentonville was closing, a transfer had to take place. In the
circumstances, I make no criticism of the transfer decision itself but an informed
discussion between the responsible psychiatrists at Pentonville and Brixton
should have taken place prior to it taking place. I endorse the clinical reviewer’s
following recommendation:
The transfer of psychiatrically ill prisoners between prisons should only take
place after a discussion between and agreement of the psychiatrists
responsible for the care of the prisoner at both ends of the transfer.
Actions after the man was taken to hospital
105. Given that the man was alive when he left Brixton, there appears to have been
some confusion over what should happen next. For a death in custody, there
are contingency plans which are co-ordinated by the duty governor, assisted by
the Orderly Officer. But although at that time it was not a death, the events of 7
March constituted a very serious incident involving D wing staff who had
witnessed a traumatic medical procedure. Some members of staff said that no
manager had spoken to them on the night, or thereafter, to discuss either their
involvement or how they were feeling. The Staff Care and Welfare team appear
not to have been made aware of the events. There was no debrief on the night
or at a later date, although one member of staff was allowed to go home as he
was very traumatised. Medical staff were not asked to provide statements of
their involvement. I think this was all very unfortunate and that, when such a
serious incident occurs, the contingency plans for a death in custody provide a
good guide to the actions to be taken.
The Governor should develop a process to ensure appropriate records are
kept and support offered to staff following a serious act of self-harm.
Family contact
106. The duty governor was responsible for co-ordinating the contingency plans
following the man’s departure to hospital. Given the serious nature of the man’s
injuries, the family had to be contacted. The duty governor said that he was
unable to find a telephone number on the LIDS system. My investigators found
a number in the man’s paper records so it is not clear why this information had
not been copied to the database. However, in the absence of a phone number,
and given the distance from the prison to the family’s home address, the duty
governor asked the police to make contact with the man’s parents to break the
news. The man’s parents said that when the police came to speak to them, they
were unable to provide even the basic facts about what had happened to their
son.
107. The duty governor did not recall giving the police a number to call at the prison
or a named person as a contact. I am quite clear that this information should
have been given and passed onto the family. In interview, the duty governor
said that he had wanted to go and visit the family the next day, but the Governor
at the time had said he should not go. The duty governor explained that there
23
was some confusion at the prison about whether or not they needed to appoint a
Family Liaison Officer (FLO) as the prisoner had not died.
108. The man’s family wrote to Brixton some days later to complain that they had not
seen a representative from the prison. Following this, on 16 March, the duty
governor and the chaplain went to meet the family at the hospital. The chaplain
then maintained some contact with the man’s family until the man died.
A family liaison officer should be identified when a serious incident of self-
harm occurs.
109. The family said that they had been led to believe by the chaplain that there
would not be any restrictions on funeral expenses. The guidance in Chapter 4
of PSO 2700, Follow up to Deaths in Custody, says that the prison “must pay
reasonable funeral expenses or, if the family want particularly expensive
arrangements, offer a contribution”. After an exchange of letters, the prison
agreed to pay the cost of the funeral in full, which was double the amount that
Governors have the discretion to pay. The dispute over the funeral payments
led to postponement of the funeral and the family blame the prison for this.
The Governor should issue guidance outlining the information to be given to
the family and the conduct of the family liaison officer.
110. Following a meeting with the man’s sisters and their solicitors, my investigator
wrote to the current Governor of Brixton drawing his attention to the family’s
concerns about the quality of family liaison. The current Governor acted
promptly and allocated another FLO to the man’s family as the chaplain who had
been acting as the FLO had retired. Concerns over missing property were then
resolved and items returned to the family, along with some private cash that was
also found. I am grateful to the current Governor for personally attending to
these matters and commend his actions.
Staffing levels on D wing at night
111. D wing Operating Procedures set out the requirements for all aspects of work in
the healthcare unit, including the optimum staffing levels. At night, they stipulate
that there should be three nurses, one discipline staff and one healthcare
assistant. After the departure of the two nurses from D wing on 7 March, there
were no qualified nurses in the in-patient healthcare unit. The workload for the
two remaining members of staff was very high given the number of prisoners
presenting with acute needs. My investigators were unable to find out why only
four staff had been working nights when five was considered to be the
appropriate level.
The Governor and Head of Healthcare should review the allocation of night
staff to D wing and, if found to be persistently operating below the optimum
level, increase the number of qualified staff placed on the wing.
The resuscitation of the man
24
112. The clinical reviewer looked in detail at the resuscitation of the man and spoke
with a healthcare officer who is responsible for CPR training in Brixton. The
emergency bag for D wing was kept in a locked cupboard just opposite D1-01.
However, at no point during the resuscitation did staff bring it out. This was
despite the fact that, once the nurses arrived back at D wing, at least five
members of staff were in attendance. The clinical reviewer judged that one of
the staff should have obtained the emergency bag from the cupboard which was
only a few feet away from them.
113. In her inspection report, HM Chief Inspector, Ms Anne Owers, commented ‘…of
particular concern was the fact that the resuscitation equipment for the in-patient
unit was kept in a locked cupboard and did not appear to be easily accessible.’
Ms Owers recommended, ‘all staff should know the location of resuscitation
equipment, which should be easily accessible at all times.’
114. The clinical review makes three recommendations about CPR.
The Clinical Review
(cid:127) The clinical review looked in great detail from a clinical perspective at the
adequacy of the healthcare that the man received at Brixton, and after he
was found hanging. The clinical reviewer raised a number of concerns,
listed below: The appropriateness of having such a seriously ill inmate on
the Hospital Wing of HMP Brixton, rather than in a secure unit psychiatric
hospital.
(cid:127) The effectiveness and appropriateness of the system for ensuring transfer
of seriously mental health patients from HMP Brixton to a psychiatric
hospital.
(cid:127) The lack of a mechanism to resolve a clinical dispute between the
psychiatrists at HMP Brixton and the psychiatrists of the secure psychiatric
unit about appropriate treatment.
(cid:127) The failure of the psychiatrist assessing the man for a second opinion, to
give an opinion on the specific reason for the referral.
(cid:127) Issues around medication for the man, especially the appropriateness of
the dose reduction of sedative medication on 7 March 2006, and the lack
of adequate medicines management support from the Pharmacy Dept.
(cid:127) The lack of a system for effective communication between the
psychiatrists providing psychiatric care on D-Wing in normal working
hours, and the GPs providing medical cover in the evenings, nights and
weekends.
(cid:127) The appropriateness of having no psychiatric cover for HMP Brixton
outside normal working hours.
(cid:127) Lack of adherence of prison staff to agreed protocols in managing the
resuscitation attempts on the man in the evening of 7 March 2006.
(cid:127) The effectiveness of the resuscitation attempt on the man in the evening of
7 March 2006, and how this could have been improved.
(cid:127) Training issues for all prison staff in managing CPR (cardio-pulmonary
resuscitation).
25
(cid:127) The lack of a significant event or critical incident analysis following the
incidents on 7 March 2006.
In addition to the issues already discussed, the clinical reviewer made a number of
additional recommendations which I fully endorse.
26
RECOMMENDATIONS
1. the Governor should urgently review the local Suicide and Self-Harm policy
to reflect the use of gated cells, including their prohibited use.
Accepted. The policy will be reviewed in its entirety, by the membership of the safer
custody meeting, which includes managers, staff, Listeners and Samaritans. The use
of gated cells has already been reviewed and a notice issued, but this will now be
incorporated into the overall policy.
2. The transfer of psychiatrically ill prisoners between prisons should only
take place after a discussion between, and agreement, of the psychiatrists
responsible for the care of the prisoner at both ends of the transfer.
Accepted. This should already happen. A meeting is being set up by London area
office to establish a London wide protocol. There are obviously occasional un-
planned transfers due to the population pressures and movements from court, police
cells etc.
3. The Governor should develop a process to ensure appropriate records are
kept and support offered to staff following a serious act of self-harm.
Accepted. Locally HR are developing a process, critical incident de-briefs and Staff
Care and Welfare offered.
4. A family liaison officer should be identified when a serious incident of self-
harm occurs.
Partially accepted. HMP Brixton recognise this is good practice, but the creation of
the FLO role was really for use in those instances where there had been a death in
custody. Use of FLOs in cases of serious self harm may not always be practicable.
There are now 3 trained FLOs at HMP Brixton.
5. The Governor should issue guidance outlining the information to be given
to the family and the conduct of the family liaison officer.
Accepted. The intention is to have trained FLOs used in such instances..
Nonetheless guidance and information will be provided for all, taken from the training
manual/package. Extensive guidance for FLOs is available as an annex to PSO
2710, Follow up to deaths in custody.
6. The Governor and Head of Healthcare should review the allocation of night
staff to D wing and, if found to be persistently operating below the optimum
level, increase the number of qualified staff placed on the wing.
Accepted. Completed. Now re-profiled. The staffing contingent for night duty on D-
wing is 2xE grade nurse, a Healthcare Assistant and 1x discipline officer. The two
trained members of staff have clinical responsibility not only for D-wing but for the
whole of the prison. There may be times when responding to a code 1 emergency
27
that both trained members of staff would go to the scene thereby leaving the
Healthcare Assistant and the discipline officer in a patrol state within that unit.
This discipline officer would always be a regular member of the healthcare team and
would continually patrol that unit carrying out intermittent supervision (every 10 mins)
which is documented.
Additional recommendations for the Clinical Review
7. The process of referring a severely mentally ill prisoner from a prison such
as HMP Brixton to a secure unit psychiatric hospital should be reviewed and
made more efficient. When a referral is made, the assessment should take
place very quickly. If the transfer to a psychiatric hospital is agreed, that
transfer should then take place as quickly as possible.
Partially accepted. It is difficult to get prisoner patients to take priority when they are
already in a custodial setting. This is a national issue and cannot be tackled by
Brixton in isolation. Work is presently being done within NHS London to move it
forward, via negotiations with the various London PCT’s and Mental Health NHS
Trusts.
Nationally pilots are currently under way to establish a transfer waiting time standard
between prisons and Mental Health units. A report on the waiting time standard is
due by end December 2007.
8. If a referral of an inmate for hospital care is refused, the psychiatrist
refusing the referral should discuss the decision with the referring
psychiatrist, if possible by meeting together at the time the decision is made.
The psychiatrist refusing the referral should participate in creating a workable
management plan for the inmate who will now continue to be cared for in
prison. This is particularly important given that currently there is no clear
process of appeal to a third party if the two psychiatrists disagree as to the
best plan. In these circumstances there should be agreed procedures as to
how to take things forward, probably including the active participation of the
prison governor and also of the local primary care trust, in this case Lambeth
PCT. It is not acceptable to leave the responsible psychiatrist at HMP Brixton
to manage a patient, if he feels that it is clinically inappropriate to have this
patient on his unit.
Accepted. HMP Brixton have a working system for engaging external psychiatrists
through CPA (Care Programme Approach) meetings. External attendance is
variable, and our experience of engaging local services in the care and treatment of
patients they have refused for admission suggests that full implementation of this will
present considerable difficulties. We agree, however, with the underlying principle.
9. If there is still disagreement about the appropriate place of care for a
mentally ill prisoner, then there should be a robust system for rapidly
resolving the disagreement, with a decision binding on both psychiatrists.
Accepted. There is presently no available appeal mechanism. One is currently being
recommended for London, along the lines of the Special Hospital Admission Panel,
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and we hope that NHS London will be able to take it forward through the Strategic
Health Authority in due course.
Nationally Strategic Health Authorities currently have a role in mediating in such
cases.
10. Lambeth PCT should move towards organising contracts for the provision
of psychiatric care at HMP Brixton that will provide for psychiatric care outside
normal working hours, and at weekends and bank holidays. This is
particularly important as it is currently not possible to admit an acutely
mentally ill inmate to an NHS psychiatric unit as an emergency.
Accepted. This clearly has substantial resource implications, but has been included
as a requirement in the service specifications for the new provider when Brixton’s
healthcare is outsourced. We need to balance this against making the prison too
much of an “acceptable” place to send the floridly psychotic and incapacitated, which
could ultimately be to the detriment of mentally disordered offenders at HMP Brixton.
There is a need for local communication, facilitated by the PCT, to ensure
emergency transfer takes place appropriately and to work towards making speedier
hospital transfers.
11. A process of significant event analysis (SEA) should be introduced for all
major incidents of self harm or significant suicide attempts. The SEA process
should also be used for all other major medical incidents. The SEA should
help to identify the learning needs of individual members of staff, as well as
the need to develop and refine systems and protocols of care.
Accepted.
12. A system should be developed to pass important clinical information
between the psychiatrists and the GPs working at HMP Brixton in relation to
prisoners who are severely ill, or are thought to be at risk of relapse or self
harm. Plans for the care of such ‘at risk’ patients should be passed on to the
GPs, as well as advice on what to do in an emergency.
Accepted. This system already exists. Clinical information is passed regarding D
wing patients via the tracking meeting, which has multi-disciplinary attendance and
takes place every Monday at 1200, and via shared medical records. The volume of
mental disorder at Brixton makes daily meetings impossible.
13. The senior psychiatrists in the prison (at consultant or specialist registrar
level) need to develop systems to ensure the accuracy and appropriateness of
prescribing of their junior members of staff. This will also help in identifying
training needs of the junior staff.
Accepted. This system is already in place. Supervision of junior staff takes place at
ward rounds, and through individual supervision sessions which happen weekly. This
is in accordance with the rules and regulations of the Royal College of Psychiatrists.
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14. In addition, arrangements should be made to ensure that a pharmacist is
present at the regular weekly ward rounds on D-Wing, to ensure full and
effective medicines management support, and to highlight problems and offer
advice to clinicians in relation to their prescribing.
Accepted. A Pharmacist will be present at the regular weekly ward rounds (currently held
on D wing on Tuesdays at 2pm). A Pharmacist will also attend D wing every week day
morning to review all prescriptions.
15. Protocols for cardiopulmonary resuscitation (CPR) should be developed at
HMP Brixton. These protocols must make it clear who is responsible for
bringing the Ambu Bag equipment to the site of any Code 1 emergency.
Accepted. Full protocol to be developed in line with the full review of the suicide
prevention policy.
16. The use of airways, such as the Guedel airways in the Ambu Bag, when
carrying out the chest inflations of CPR should be encouraged. This may
require more training of staff in order to improve the knowledge and
confidence of the staff in the use of airways.
Accepted. All training delivered encourages the use of the airways and is refreshed
annually.
17. Training procedures for prison staff in CPR need to be looked at again
particularly in terms of the use of artificial airways. Other areas of training
need in CPR should be re-examined. The frequency of refresher training for
staff may need to be reassessed, to ensure that all staff can administer CPR to
the highest possible standard.
Partially accepted. As above, refresher training for all Healthcare staff is delivered
annually, and is up to date. To include all prison staff would not be viable. We would
certainly not expect prison officer grades to carry out invasive techniques such as
the insertion of oropharyngeal airways.
18. The training needs of the GPs working at HMP Brixton in terms of their
work with severely mentally ill prisoners should be identified and met.
Accepted. The patient client group at HMP Brixton is a complex group presenting a
range of challenging needs. Working within the custodial environment also presents
new challenges. The training requirements of GP’s will be reviewed by Lambeth
PCT.
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