Individual at Bristol

Investigation into the circumstances surrounding the
death of a man at HMP Bristol in May 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2009
This is the report of an investigation into the apparently self-inflicted death of a
man in the custody of HMP Bristol on 8 May 2008. On 7 May, he was
arrested at his parents’ home and taken into police custody. The next day, he
was sentenced to 27 months for perjury. He was taken to HMP Bristol where
he died eight hours later. The man was 26 years old, and had been addicted
to heroin for ten years. It was his first time in prison.
I offer my sincere sympathies to the man’s parents and sister, and to all those
affected by his loss. I must also apologise for the delay in completing this
investigation. I trust this report will address all the concerns that the family has
raised.
I appointed an investigator from my team to investigate the circumstances
surrounding the man’s death on my behalf. I would like to thank the Governor
of Bristol and the investigation liaison officer for the support they gave to the
investigation process.
I am also grateful for the clinical review conducted into the man’s medical care
for the short time he was in prison, commissioned by Bristol Primary Care
Trust (PCT).
I was seriously concerned by what this report reveals about reception
procedures at HMP Bristol, and I understand they are now under review. My
report also examines the prison’s new detoxification unit, opened just two
days before the man died, and where he was found hanging.
While in court cells, the man had been subject to constant supervision and a
suicide and self harm warning form had been completed. In retrospect, it is
utterly clear that the man should also have been subject to monitoring and
support under the Prison Service’s ACCT system. I make six
recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2009
CONTENTS
Summary 4
The Investigation Process 6
HMP Bristol 7
Key Events 8
Issues 17
Conclusion 26
Recommendations 27
SUMMARY
The man was taken into custody by the police on 7 May 2008. He had failed
to appear for court in April in connection with a charge of perjury. The man
was in police custody overnight and there were no concerns that he was at
risk of self harm. The following morning, he was taken to Crown Court and at
11.00am was sentenced to two years and three months. It was to be his first
time in prison.
Despite appearing to be cheerful when he left the court room, the man was
later found in his cell by court staff to be in an agitated state. When a court
officer noticed red marks around the man’s neck, she checked his records
and found that he was said to have no previous history of self harm.
Nevertheless, she made the man subject to constant supervision and
completed a suicide and self harm warning form.
The man was collected from court and taken to HMP Bristol where he arrived
at about 1.00pm. The reception officer signed to acknowledge receipt of the
court’s suicide and self harm warning form, but thought that the man was
particularly relaxed considering that it was his first time in prison. He did not
open the prison’s suicide prevention measures.
While in reception, a nurse conducted a first reception healthscreen during
which she identified that the man needed to go through detoxification. (The
man had been addicted to heroin for ten years and frequently drank alcohol.)
She spoke to him about his physical and mental health and he told her that he
had no thoughts of self harm. The nurse did not have the court warning form
while conducting the healthscreen, but was given it afterwards. The nurse
spoke to the man about the court staff’s observations and he assured her that
he was not thinking of harming himself. Despite noticing red marks around
the man’s neck, and taking into consideration his other risk factors, the nurse
did not start suicide prevention measures either. She filed the warning form in
a later section of the clinical record and made no note of it.
Two days before the man’s arrival, Bristol had opened a new drug treatment
unit intended to assess and treat a prisoner’s substance misuse needs from
their first night in custody. Following the reception nurse’s assessment, the
man was due to be transferred for detoxification. Before he was moved to the
new unit, he had a first night interview with an induction officer in reception.
He told the induction officer that he had no thoughts of self harm. The
induction officer neither saw the court warning form nor noticed the red marks
around the man’s neck.
The induction officer escorted the man to the new drug treatment unit at about
3.00pm. They arrived as medication was being distributed so no staff from
the unit were free to look after the man. The induction officer was asked to
locate him in an empty cell, which he did. The treatment hatch on that cell’s
door was too high, which obscured some staff’s view into the cell. There was
also a nail affixed to the wall that served no discernible purpose. The man
passed the afternoon in the cell, leaving it once to collect his meal.
The new unit’s routine was running late that day. At about 7.00pm, the man
was one of three prisoners taken for assessment by the doctor. The doctor
prescribed chlordiazepoxide and a low dose of methadone (medication used
for detoxification). He made a mental health assessment and did not assess
the man as at risk of suicide or self harm. The doctor did not see the suicide
and self harm warning form, although he did have the clinical record. In
interview, he remembered that there were no red marks on the man’s neck.
A prisoner would usually have the opportunity to use the telephone after he
has seen the doctor. However, as the regime was running late, the man
returned to his cell at about 8.30pm without using the telephone. He was
discovered hanging in his cell less than an hour later during the distribution of
medication. He had attached a ligature to the nail in the wall. Following
resuscitation attempts, the man was taken from the prison in an ambulance.
Sadly, he died before he reached the hospital.
My investigation explores the assessment of the man’s risk of self harm
throughout his brief time in prison. I make recommendations about the first
reception healthscreen process and the consideration of risk in reception. I
also examine the man’s location in the new drug unit, and the physical
environment of that unit, and make related recommendations.
THE INVESTIGATION PROCESS
1. I appointed one of my investigators to lead the investigation into the
man’s death. The investigator visited Bristol on 15 May and met the
Deputy Governor, Chaplain, and representatives from the Independent
Monitoring Board, the Prison Officers’ Association and the Prison
Governors’ Association. The liaison officer for the investigation provided
the investigator with copies of the man’s records and arranged for her to
be shown around the prison. Notices were posted around the prison
inviting staff and prisoners to contact the investigator with any matters of
relevance to the investigation. There was no response to the notices.
2. I am grateful to Bristol Primary Care Trust for the commission of a
clinical review into the care that the man received during his short time at
Bristol. After a review of the paperwork, the investigator and the clinical
reviewer returned to Bristol on 17 June to carry out interviews with
healthcare staff.
3. During the course of the investigation, matters came to light relating to
reception procedures that required urgent attention to ensure the
continued safety of prisoners. My investigator kept the Governor
informed of such matters as they arose so that he could take action as
required.
4. Two prisoners arrived at Bristol at the same time as the man but had
been transferred by the time of the investigation. The investigator wrote
to them asking for their views on the reception process. Unfortunately,
they did not respond to her letters.
5. The Detective Constable (DC) who led the police investigation into the
man’s death interviewed the court staff and escort officers who had
contact with the man on 7 and 8 May. The investigator liaised with the
police, who kept her informed of her findings. The DC provided the
investigator with the statements taken from court and police staff who
had contact with the man in the 24 hours before his death. I am grateful
to Avon and Somerset Constabulary for their support during the
investigation.
6. My Senior Family Liaison Officer, accompanied the investigator on a visit
to visit the man’s parents on 25 June. I would like to thank them for their
contribution at such a sad time in their lives, and I trust that this
investigation report answers their questions.
7. Further interviews were carried out with staff in August and September
and the investigator met the operational lead from the Department of
Health to discuss the Prison Service’s delivery of substance misuse
services.
HMP BRISTOL
8. HMP Bristol is a local prison, located in a largely residential area in the
middle of the city. It can accommodate up to 606 adult male prisoners.
Her Majesty’s Chief Inspector of Prisons, Dame Anne Owers, carried out
her most recent full announced inspection of Bristol in 2005. The prison,
especially in respect of prisoners’ detoxification, has changed a great
deal since then. At the time of her inspection, the Chief Inspector found
that “the clinical management of the detoxification processes was
effective,” although prisoners undergoing detoxification spent too much
of their day locked up. She recommended:
“Prisoners undergoing detoxification should be in an environment
where they can be observed by specialist staff and have access
to a supportive regime. A dedicated detoxification unit should be
developed to meet this need.”
9. In the Independent Monitoring Board’s (IMB’s) annual report for 2006/7
they comment, “the physical environment of the reception area is quite
unsuitable for the twenty first century.”
10. The IMB go on to note the “high quality of staff and prisoner relations”.
They welcome the commissioning of healthcare by Bristol PCT and the
review of the necessary skills mix that accompanied it. The Board
consider the new IDTS unit “a requirement”.
11. Following my investigator’s interim feedback to the Governor, the Prison
Service South West Safer Custody Adviser commissioned a review of
the first reception healthscreen process. I will discuss the findings of the
review later in this report. It is the last annex to the report.
12. The man’s death was the only apparently self-inflicted death at HMP
Bristol in 2008.
Integrated Drug Treatment Service (IDTS)
13. Bristol opened their dedicated detoxification unit on 6 May 2008. The
unit was funded from the new Integrated Drug Treatment Service (IDTS)
which has been rolled out nationally over the last two years. The
purpose of the dedicated unit is to assess and diagnose prisoners’
substance misuse needs on the day of their reception into the prison and
provide a structured detoxification programme. Prisoners progress
through the regime until they are ready to move to a residential wing. A
doctor is assigned to the unit every evening between 6.00pm and
8.00pm and designated nurses are on duty 24 hours a day.
KEY EVENTS
14. The man lived in the Bristol area all his life. He was close to his family,
especially his mother, and they spoke every couple of days. Despite his
substance misuse problems, his family said that he was never
aggressive and they described him as “happy”.
15. The man first used heroin when he was 16 years old. On several
occasions over the following ten years, he sought medical advice to cope
with his addiction, he but never overcame it. He had no criminal record
until the events that led to his imprisonment.
16. The man was due to appear in Crown Court on 11 April 2008 charged
with perjury. He failed to appear and a warrant was issued for his arrest.
For just under a month, the man continued living in the Bristol area but
did not present himself to the police. On Wednesday 7 May, the man
went to his parents’ home. His mother told my investigator that he
seemed relaxed but she was worried about his physical appearance.
Both parents felt that the man would receive the help he needed to deal
with his addictions in prison. They contacted their local police station to
notify them of his whereabouts.
17. At about 11.00pm that night, two police constables arrested the man in
his parents’ home. (Police officers and court staff made statements to
Avon and Somerset Constabulary following the man’s death, and these
were passed to my investigator.) The man was taken to Trinity Road
Custody Unit. While on his way to the custody unit, he told officers, “the
last time I was in custody I hid drugs in my mouth and I’ve got something
left to eat today.” The police officers said in their statements that they
thought the man meant he was hiding drugs and ordered a full strip
search when he reached the custody unit. The strip search was
authorised by a senior police officer. No drugs were found.
18. While police officers were completing the paperwork that evening, the
man chatted to them. According to their statements, he seemed “calm
and light hearted”. He joked with them, asking them to guess what his
offence was. The man spent the night at the custody unit subject to
hourly checks. (These checks are routine and are carried out for anyone
being held at the unit.) None of the officers involved in the arrest or
custody of the man that night had particular concerns about his
wellbeing.
19. At 8.00am the next morning, two escort officers employed by Reliance
Custodial Services, escorted the man from the custody unit to Crown
Court. During the journey, the man said he was “tired and a bit cold”.
He was given his coat to keep warm. According to one of the escort
officers, the man “showed no outward signs of any problems”. One of
the escort officers did not see the man again, but the other stayed at the
court to continue her duties. As a matter of routine, the man was
checked at least once an hour.
20. The man’s solicitor visited him at 9.55am for 15 minutes to discuss his
court appearance. At 11.00am, he was sentenced to two years and
three months. His parents were at court and told my investigator that
they were surprised at the length of the sentence and thought that the
man would be too. However, the man’s mother remembered him trying
to cheer her up as he left the courtroom. He told her not to worry about
him and was smiling. The man went back to his court cell at 11.20am.
21. Two court officers were near the cells when the man returned. In their
statements, they both recalled that he seemed “upset and agitated”.
One of the officers went into the man’s cell at 11.30am to give the man
his lunch. She said: “ … he was hiding behind the door, as I opened it
he jumped back quickly and put his hands around his neck.” One of the
court officers gave the man his lunch and then left the cell, closing the
door. She asked the other court officer “to keep a close eye” on the man
while she checked his records to see if there were any warnings about
vulnerability. On checking the paperwork, that court officer found that no
concerns had been raised apart from his drug and alcohol misuse.
22. The court officer went back to the man’s cell. She and the other court
officer then noticed that he had red marks around his neck. The officers
searched the man and his cell for any objects that he might use to harm
himself. They removed his coat and moved him to a cell where he could
be supervised constantly. The first court officer opened a suicide and
self-harm warning form on which she wrote the man was displaying
bizarre behaviour, seemed very depressed, and had reacted badly to his
sentence. (A suicide and self harm warning form records details of the
current or past risk of self harm, where relevant, and it accompanies the
prisoner as he is transferred to prison.) The officer noted:
“The man was acting very strange on entering cell. Noticed
severe red marks around his neck and looked like he had
attempted to strangle himself. Also banging his head on cell wall.”
23. An escort officer collected the man from his court cell at 12.30pm. When
he arrived at the prison, he was shown to a holding cell to wait for his
details to be checked. There were two other prisoners who arrived with
him that afternoon and they were called one by one. The man was
called to the reception desk and a reception officer checked his personal
details. The reception officer had access to the man’s prisoner escort
record (PER) and his warrant. The escort officer brought a copy of the
suicide and self harm warning form to Officer the reception officer’s
attention because it had not been signed upon his first arrival. The
reception officer signed to acknowledge its receipt at 1.00pm. The
escort officer took a copy of the form and returned it to the court for their
records. The reception officer remembered asking the man about the
suicide and self harm warning form and he dismissed the suggestion that
he had self harmed while at court. (A cell sharing risk assessment is
carried out in reception to determine whether it is safe for a prisoner to
share a cell with another prisoner, or if it would place the prisoner or his
cellmate at risk.) Overall, the reception officer assessed the man’s risk
to others as “low”, although noted his substance misuse needs.
24. The man’s possessions were recorded and placed in a sealed plastic
bag. He was strip searched (as are all prisoners coming into prison) and
issued with prison clothing. At about 2.30pm, the man was taken to a
private room for his first reception healthscreen. (A first reception
healthscreen is an interview by healthcare staff which takes place when
a prisoner arrives at the prison. It should determine any physical or
mental health conditions that require treatment, any substance misuse
matters that need to be addressed, and any risk that the prisoner may
pose of harming himself or attempting suicide.)
25. At the time, the reception healthscreen nurse was a Prison Service nurse
who had worked at Bristol since 1997. From 2003, her main duty was to
complete first reception healthscreens and train other healthcare staff in
their completion. She explained to my investigator that the healthscreen
is a conversation with a prisoner. She does “not generally” have the
prisoner’s custodial file, unless there is some healthcare information from
a community or court doctor.
26. The nurse said that the man may have been the first prisoner she
interviewed that day and there were only three prisoners in reception at
the time. The reception healthscreen nurse asked him about his
physical health. He told her that he had not seen a doctor for a few
months and had no outstanding appointments. He added that he was
not receiving any prescribed medication. The man said that he had
problems with “epilepsy or fits”. During interview, my investigator asked
the reception healthscreen nurse for more information about the type of
fits that the man had, but she could not recall the exact detail. She said
she thought that his fits were probably related to his use of alcohol, and
she knew that the man would see the doctor in the IDTS unit for a further
examination later in the day.
27. No concerns about the man’s physical appearance were recorded on the
healthscreen. The man told the reception healthscreen nurse about his
substance misuse. He said that he drank four to five cans of premium
lager daily. (According to NHS guidelines this is between 16 and 20
units of alcohol. Men should not regularly drink more than three to four
units of alcohol per day.) He used heroin three to four times a day and
cocaine/crack on a daily basis. The man had taken drugs intravenously.
The nurse remembered he was “pale” during the healthscreen, but
otherwise did not observe any signs of withdrawal.
28. The next section of the healthscreen explores a prisoner’s mental health
and vulnerability. The reception healthscreen nurse asked the man
whether he had ever received treatment in the community for mental
health problems and he said that he had not. She asked if he had tried
to harm himself either in prison or outside prison and recorded that he
had not. The man told the nurse that he was not thinking of harming
himself. When asked to record her impression of the prisoner’s
behaviour and mental state, the reception healthscreen nurse indicated
that there was “nil of note”.
29. When asked during interview what kind of behaviour she would record in
that section, the nurse explained: “if somebody was tearful or crying or
very, very low in mood, very poor eye contact, anything like that”. If the
reception healthscreen nurse thought the man had ever tried to harm
himself or was considering self harm, the form would have prompted her
to consider opening an ACCT document. (ACCT, Assessment, Care in
Custody and Teamwork, is the Prison Service’s system used to monitor
and support prisoners at risk of suicide or self-harm.) She did not open
an ACCT document following the healthscreen.
30. When the healthscreen was complete, the reception healthscreen nurse
went on to complete the healthcare section of the cell sharing risk
assessment. She did not complete questions one or two of the section
which asked whether there was evidence to suggest that the man was at
risk of harming others. In response to the question: “following the self-
harm assessment have any concerns been raised?” the reception
healthscreen nurse responded that none had been identified. However,
she went on to write “detox” on the large blank section of the form. The
form was then passed to the induction officer who conducted the man’s
first night assessment and located him in his cell on C-wing.
31. As part of the reception screening, the reception healthscreen nurse took
a urine sample to test for drug use. The man’s urine sample tested
positive for opiates (heroin), cocaine and benzodiazepines (sedatives).
The results were known immediately and filed for assessment by the
doctor later that day.
32. After the reception healthscreen nurse completed her assessments, the
man was shown to a holding room where he waited on his own to be
taken to the IDTS unit. A few moments later, the nurse was handed the
self harm warning form completed by court staff earlier that day. The
reception officer had noticed it lying in the tray where the paperwork is
prepared for the healthscreen. He thought the nurse had accidentally
left it in the tray but judged it was important and so brought it to her
attention. When he did so, the reception officer remembered telling the
reception healthscreen nurse that he thought it odd how relaxed the man
appeared, despite it being his first time in prison.
33. The reception healthscreen nurse went to speak to the man about the
information from the court staff which was recorded on the form. The
man told her that he was fine. The nurse noticed that he had red marks
around his neck but did not ask him about them. Again, she did not
open an ACCT document. She asked the man whether he was going to
harm himself and he assured her that he was not. My investigator asked
the reception healthscreen nurse whether she considered anything other
than the man’s verbal responses, such as his body language, when
considering his risk of self harm. She said: “No, nothing else. I just
simply went on what he told me.”
34. The IDTS unit had opened just two days before the man’s arrival at
Bristol. It is a discrete wing for prisoners who need to undergo
detoxification. Its purpose is to assess a prisoner’s substance misuse
needs and begin their detoxification on the day of their arrival. Hence,
the man was allocated a cell on C wing, which is where the IDTS unit is
located.
35. Every prisoner at Bristol goes through a first night assessment with a
member of the induction team. For those who are allocated to the IDTS
unit, the first night assessment takes place in the reception area. An
induction officer carried out the man’s first night assessment in private in
the holding cell. The man told the induction officer that he was
“probably” expecting to be in prison that day, but that this was his first
time in prison. He said that he was “slightly concerned” about being in
custody and described himself as an “addict”. The man told the officer
that he had “never” committed any acts of self-harm and he did not feel
at risk of doing so. The induction officer recorded that the man was
“polite” and “co-operative” during his interview.
36. As part of the assessment, the induction officer asked the man if he felt
at risk of suicide or self harm and he assured him that he was fine.
During his interview for this investigation, my investigator showed the
induction officer the court staff’s suicide and self harm warning form.
The officer had not seen the form before the interview. He said that if he
had seen the warning form he would have discussed it with the nurse
and reception staff and started the ACCT process. The induction officer
said he had the man’s wing history sheet. He also had an induction
information pack to give to the man. There was no mention of the
suicide or self harm warning form in the papers. During interview with
my investigator, the officer could not recall noticing whether there were
red marks on the man’s neck during their conversation.
37. Sometime between 3.00pm and 3.30pm, the induction officer took the
man to the IDTS unit. When they arrived, medication was being
dispensed to prisoners. Usually, the officer escorting the prisoner from
reception to the IDTS unit would hand over to a nurse who would
allocate the prisoner’s cell. On this occasion, the nurses were busy
dispensing medication and so the induction officer located the man in a
cell away from the treatment hatch. The officer said that he walked into
the cell with the man and remembered that there were bunk beds in
there, joking that the man had the choice of beds. There was a radio in
the cell, but no television. The man had the induction pack to read
through. The induction officer recalled:
“I said make yourself comfortable, chill out now, have a fag if you
like because he was unable to smoke down in reception and I’d
given him the smokers’ pack, he could now have a fag. Gave him
all the paperwork, reminded him to read it and then I said shortly
you’ll be having your tea and then the staff will see to your needs
later.”
38. My investigator asked the induction officer whether he recalled a nail in
the wall opposite the cell door or that the treatment hatch was unusually
high. The officer did not recall either of these facts. In fact, there was a
nail in the wall next to the window. It served no discernible purpose, but
must have been there since the refurbishment of the unit. Some of the
cells had also been fitted with incorrect doors, leaving the treatment
hatches too high for some staff to clearly make observations. The nurse
in charge of the unit told my investigator that there were cells with
correctly fitting doors which were used by IDTS staff in preference to
those with higher treatment hatches. However, the man was not located
in his cell by a member of the IDTS unit and was located in a cell with a
higher treatment hatch. The induction officer did not usually work on the
unit and had no reason to know about the problem with the doors, and
IDTS staff were occupied with the distribution of medication and running
the unit’s regime.
39. The man’s family were concerned that they had not been telephoned by
him on the night that he arrived at the prison. They asked my
investigator to ensure he had the opportunity to use the telephone. The
induction officer had explained the telephone system to him and issued a
code to enable him to use the telephone as part of the induction process.
The man was given 50p telephone credit, sufficient to make one
telephone call, in accordance with normal procedure. The induction
officer explained that, on the induction wing, the man would have had the
opportunity to use the telephone at tea time, around 5.00pm. The nurse
in charge of the unit told my investigator that prisoners normally get the
chance to use the telephone once they have had their medical
assessment. The man’s telephone records show that he made no
telephone calls that afternoon or evening.
40. The man remained in his cell for most of the intervening four hours, only
coming out to collect his meal. He was not subject to ACCT procedures
(the system to manage risk of suicide or self harm) and so he was not
checked. Prisoners on the IDTS units are checked at irregular intervals
and the nurse in charge of the unit estimated that the man would not
have gone for longer than 40 minutes without someone observing him.
Observations are not recorded unless there is something of note. No
observations were recorded in the man’s clinical record that afternoon.
41. At about 7.00pm, the new prisoners on the IDTS unit were taken to the
doctor’s waiting room. (As part of the IDTS scheme, a doctor must
assess the substance misuse needs and mental health of each prisoner
requiring detoxification on the unit on the day they arrive.) During his
interview with my investigator, the doctor recalled that the man was the
last of the three prisoners to be assessed that evening. He used the
“Initial GP Screen”, “Hypno-Sedative Withdrawal Scale” and “Clinical
Opiate Withdrawal Scale” to assess and record the man’s symptoms and
needs. (These are forms used to record a patient’s symptoms of
withdrawal from drugs to assess their level of dependency.) During
interview, the doctor said that the man appeared to have mild symptoms
of withdrawal, including moist skin, agitation and uncertainty about the
date. The doctor had access to the man’s medical record, including the
nurse’s first reception healthscreen. The doctor understood that the man
would withdraw from alcohol and prescribed chlordiazepoxide to treat the
symptoms of alcohol withdrawal. He said that he was satisfied that the
man’s urine sample indicated a genuine need for detoxification. The
doctor explained that the policy at Bristol is to prescribe a low dose of
methadone and gradually increase the amount, in accordance with the
prisoner’s needs. He said, “we are very cautious to prescribe
[methadone] and of course the patient himself may not give you the
accurate dates.” In accordance with his usual practice, the doctor
prescribed the man 10mg of methadone that night.
42. The man’s family told my investigator that they were concerned that he
had not understood that he would receive methadone that evening. It
was their opinion that he would not have self-harmed if he knew he
would receive methadone, even such a low dose. My investigator asked
the doctor if he explained to the man that he would receive methadone
that evening. The man could not recall whether they specifically
discussed the dose but was confident that the man knew he was going
to receive methadone.
43. As well as assessing the man’s substance misuse needs and prescribing
appropriate medication, the doctor assessed the man’s mental health.
The doctor is experienced in mental health treatment. He told my
investigator that such an assessment will always take into account
whether the prisoner is at risk of self-harm or attempting suicide. He
said that he examined the head area as a matter of routine and did not
see any red marks on the man’s neck. Despite having the man’s
medical record to inform his assessment, the doctor did not see the
suicide and self harm warning form. It is likely that the document was in
the medical record at the time of the assessment. My investigator
looked at the original copy of the medical record and a copy of the form
was filed in a later section, with no reference made on the front page,
entitled “Significant Events”. The doctor did not assess the man as
being at risk of self harm. He explained to my investigator that he
thought that the man was “not in the slightest” at risk of self harm.
44. The man went back to his cell at about 8.30pm. The doctor and the
IDTS nurse on duty that night went to the healthcare centre to collect
methadone ready to dispense. Methadone is measured in the
healthcare centre and brought over to the unit ready to be dispensed.
45. The doctor remembered that there were only about five prisoners on C
wing that night. He put the man’s medication outside his door for ease
and continued to distribute the medication to each prisoner on the wing
with the IDTS nurse. The man’s was the last cell that they came to at
9.15pm. The IDTS nurse opened the observation panel. Due to the
height of the panel, the nurse mistakenly thought that the man was
standing by the window with his eyes closed. The nurse called to the
man several times. There was no response.
46. The nurse realised that something was wrong and ran to fetch an officer.
(Nurses do not carry cell keys during an evening shift.) The doctor also
looked through the observation hatch and saw the man hanging. The
doctor ran to the telephone in the landing office and dialled 222, the
number used to contact the communications room in an emergency. He
then made his way to the first landing, down two flights of stairs, to get
the emergency treatment kit including a defibrillator. Following a request
from an officer, an ambulance was called two minutes after the
emergency call at 9.20pm.
47. In the meantime, the IDTS nurse had asked an Operational Support
Grade (OSG) to open the man’s cell for him. The OSG looked through
the observation hatch and saw the man hanging. He could see a white
ligature that “looked like a sheet” around his neck. The OSG made a
radio call of “Code Blue” which means medical emergency - breathing
difficulties. He then asked for permission to break the sealed pouch
issued to staff on a night shift which contains a cell key. Permission was
granted and he went into the cell. The OSG took the man’s weight and
cut the ligature with the anti-ligature knife attached to his belt. The IDTS
nurse and the OSG lowered the man to the floor. The OSG removed the
ligature from around the man’s neck and started chest compressions,
while the IDTS nurse performed mouth to mouth resuscitation.
48. The doctor returned to find the two members of staff performing cardio-
pulmonary resuscitation (CPR). The doctor applied the defibrillator,
which instructed him not to use it. The doctor thought that the
defibrillator was not in full working order so he instructed the nurse to
obtain another defibrillator. The doctor took over chest compressions
and administered the ambu-bag (a device used to introduce oxygen via
the mouth). The doctor then applied a second defibrillator but there was
still no cardiac activity and he was again instructed not to shock.
49. The paramedics arrived around 20 minutes after the ambulance was
called.
50. An officer was stationed by the prison gate ready to escort the
ambulance and the paramedics to the man’s cell. The paramedics took
over resuscitation attempts, and the doctor remained in the cell. During
interview, he said that the paramedics’ treatment was excellent. They
inserted an airway into the man’s throat and, due to a small output on
their heart monitor, decided to take him to hospital. The officer by the
gate was asked to help the OSG carry the man downstairs on a
stretcher.
51. The doctor said in interview that he was not optimistic about the man’s
chance of survival when he left the prison. In fact, the paramedics
stopped CPR in the ambulance. The officer accompanying the man rang
the prison at 10.17pm to tell them that the man had been pronounced
dead. The ambulance continued to the hospital and a hospital doctor
certified the man’s death on arrival at 10.35pm.
Contact with the family
52. The man’s parents were informed of their son’s death at about 1.00am.
As noted, the prison had been informed at 10.17pm by the officer who
had gone with the man in the ambulance. However, the police advised
prison staff not to break the news to the family without a police escort.
Prison Service Order (PSO) 2710 – Follow Up to Deaths in Custody (the
Prison Service’s guidance for family liaison) recommends that the news
of a prisoner’s death should be given in person by a Prison Service
representative. The PSO goes on to acknowledge that the police may
advise that an escort is necessary.
53. Given the police advice, it was appropriate for the prison to wait for a
police escort before breaking the news of his death to the man’s family.
Unfortunately, the police did not arrive at the prison to escort the
chaplain and the prison family liaison officer (FLO) to the man’s family
home until 12.30am. Although the prison FLO was the designated family
liaison officer, the family requested that their main point of contact should
be the Chaplain.
54. After breaking the news, the chaplain returned to the prison for the hot
debrief. (This is a meeting between all staff involved in a death in
custody to discuss what happened and share any concerns.) The
meeting was convened at about 4.00am. Around five minutes into the
meeting, the man’s family arrived at the prison, wanting to speak to
someone regarding their son’s death. The Duty Governor asked the
chaplain and the Night Orderly Officer to meet them. The family were
told that due to security restrictions, they could not come inside the
prison during the night. They agreed to return the next day.
55. The family were particularly concerned by the Night Orderly Officer’s
manner during their exchange. They felt that he did not take their
situation seriously. When my investigator put this to him during
interview, the Night Orderly Officer was surprised that they had
interpreted his manner in that way. He assured my investigator that he
tried to deal with the situation sensitively. The Night Orderly Officer has
not had training in family liaison, but I trust that he did his best and the
family misunderstood his manner. Although my investigator did not
speak to the Duty Manager during the investigation, he responded to this
issue following the advance disclosure of the report. The governor
explained that his decision not to speak to the family personally was
based on “a number of reasons, including the security of the prison,
following contingency plans and the care of staff”. However, I am still
surprised that the Duty Governor did not speak to the family himself. If
such a tragedy should occur again in the future, I would expect the most
senior member of staff in the prison to deal with it personally.
56. The following morning, the Governor, Deputy Governor and Head of
Residence met the family. The family asked to visit the cell where the
man had died and collect his property. Their visit was arranged for the
following week. The Governor offered to pay for the man’s funeral
expenses, in accordance with national policy.
57. The man’s family were concerned that the information they received on
the early morning visit to the prison was inaccurate. They had been told
that the man had been found hanging by a doctor, but their
understanding was that no doctor worked in the prison at such a late
hour. In fact, the IDTS unit requires that a doctor is on site from 6.00pm
until 8.00pm every evening. The late running of the newly opened unit
meant that the doctor was still carrying out his duties at the late hour of
9.15pm.
58. In addition, his parents were also worried that the man was able to hang
himself from what appeared to be a nail left in the wall during the refitting
of C wing. Understandably, they found it hard to believe that the man’s
risk of self-harm or suicide had been identified at court, but that this risk
was not monitored at the prison. I will examine these matters in detail
later in the report.
Staff Support
59. As I have said above, a hot debrief was held at 4.00am. It is a difficult
balance for prison management to hold a timely meeting in such
circumstances without compromising the police investigation or placing
too great a demand on staff. Staff all told my investigator that they
understood that the debrief was necessary and they found it helpful.
They said they were well-supported on the night and could access the
staff care and welfare team if they needed to.
ISSUES
Should the prison have identified the man as at risk of suicide?
60. The man was identified as at risk of self harm at Crown Court. He was
subject to constant supervision in the court cell. Information about his
alleged attempt to harm himself was recorded using the suicide and self
harm warning form. The reception officer acknowledged receipt of the
warning form when he interviewed the man in the reception area of the
prison, shortly after his arrival.
61. The reception officer told my investigator that he remembered the form
and had asked the man about it. He is experienced at working in
reception. Upon receipt of such a form, the reception officer told my
investigator that he assesses a prisoner’s risk of suicide or self harm.
He said that he remembered the man as being surprisingly relaxed about
his first time in prison. He recalled seeing red marks on the man’s neck
but described them as “superficial”, as if the man had repeatedly rubbed
his neck. The officer did not think the marks could have been a result of
self harm.
62. The reception officer is trained in ACCT procedures. However, he said
that when he considers a prisoner to be at risk of self harm, he usually
brings it to the attention of the first reception healthscreen nurse rather
than opening an ACCT himself. Taking into account the man’s relaxed
demeanour and his denial of thoughts of self harm, the reception officer
did not consider the man at risk of harming himself. The reception officer
put the self harm warning form with the man’s file ready to be collected
by the nurse for the first reception healthscreen and did not bring it to her
attention at that time.
63. Prison Service Order (PSO) 2700 – Suicide Prevention and Self-Harm
Management sets out the requirements for managing prisoners identified
as at risk of self harm. There is a section in the PSO relating to
prisoners who have been received into prison with a suicide or self harm
warning form. The warning form is on carbon paper which duplicates
three times. The top white copy should go into the clinical record. The
third pink copy goes with the escort staff, and was taken by the escort
officer in this case. The PSO requires that the second yellow copy
should go into an ACCT document, if one is opened. If an ACCT is not
opened, then the yellow copy of the suicide and self harm warning form
should be put in the core record. A note should also be made in the
case notes section of the wing history record. The reception officer did
not put a copy of the suicide and self harm warning form into the man’s
core record.
The Governor should remind reception staff of the requirement to
file a copy of any suicide and self harm warning form in the
prisoner’s core record.
64. The nurse that completed the first reception healthscreen told my
investigator that the purpose of the healthscreen is to determine the
immediate needs of a prisoner. The reception healthscreen nurse was
confident in ACCT procedures and said she had opened many ACCT
documents in her role. According to the reception officer, when the
reception healthscreen nurse first collected the man’s files to inform her
healthscreen, she did not pick up the self harm and suicide warning
form. The reception officer remembered noticing the form in the tray and
interrupting the man’s healthscreen to pass the form to the nurse. The
nurse remembered being given the form after the healthscreen had
finished. When he gave her the form, the reception officer said he also
mentioned to the nurse that he thought that the man’s relaxed
presentation was at odds with it being his first time in prison.
65. The reception healthscreen nurse said that she assessed the man’s risk
according to his presentation and what he told her during the
healthscreen. During her interview with my investigator, she said that
she does not take into consideration a prisoner’s body language as a
measure of their risk. After being given the self harm warning form, she
went to speak to the man in the holding cell. She noticed the red marks
on the man’s neck but did not ask him what happened at court earlier
that day. The nurse acknowledged to my investigator that she knew it
was the man’s first time in prison, that his substance misuse needed
immediate treatment, and that she was aware of the attempted self harm
earlier at court. Despite these significant risk factors, the reception
healthscreen nurse did not consider the man to be at risk of self harm.
The nurse had been employed as a Prison Service nurse at Bristol for 11
years. For the previous five years before the man’s death, her principal
role was carrying out first reception healthscreens. I am extremely
concerned about the reception healthscreen nurse’s judgement in this
case.
66. During the investigation, the clinical reviewer and my investigator
discussed the adequacy of the first reception healthscreen. The clinical
reviewer concluded that the reception healthscreen nurse’s assessment
was “significantly below” the standard needed for a first reception
healthscreen. Their conclusions were fed back to the Governor and an
agreement was reached that he should consider a disciplinary
investigation into the actions of that nurse. In such cases, where
recommendations might have an immediate impact on the safety of
prisoners, early notice is given to the Governor. When my investigator
contacted her liaison officer to explain that a disciplinary
recommendation would arise from the investigation, she was informed
that the reception healthscreen nurse had already resigned from her
post. I therefore make no further recommendation.
67. The reception healthscreen nurse was given the suicide and self harm
warning form, she initialled and filed the form in the clinical record. PSO
2700 sets out the following requirement:
“Upon receipt of the suicide and self harm warning form and the
PER, the reception healthcare screener must decide, having
spoken to the prisoner and considered all other information
available, whether to open an ACCT plan. If the prisoner has
self-harmed during the time spent that day (or possibly longer if
a new arrestee) under escort supervision, at court, in transit, or
while in police custody then the reception healthcare screener
must open an ACCT plan.”
Despite noticing red marks on the man’s neck, the nurse believed his
account that he had not self-harmed at court. As a result, she did not
open an ACCT, but she should have considered doing so. She assured
my investigator that she considered that the man was not at risk of self
harm and so did not open an ACCT document.
68. The reception healthscreen nurse did not make any record of the
warning form on the front page of the record, which is a sheet entitled
“Significant Events”. As she was given the warning form after she had
completed the healthscreen, she did not amend the first reception
healthscreen to record the additional information about the man’s risk.
The Head of Healthcare should remind healthcare staff completing
first reception healthscreens that all information about risk of self
harm or suicide should be noted on the “Significant Events” page
of the clinical record.
69. My investigator originally asked the clinical reviewer to write to the
Nursing and Midwifery Council with details of the reception healthscreen
nurse’s involvement in the man’s care. During the draft consultation
period, the Chief Executive of Bristol PCT clarified that the nurse was
employed by the Prison Service and had resigned from her position.
70. The reception healthscreen nurse was the most experienced first
reception healthscreen nurse at Bristol. As part of her role, she trained
other nurses to complete the assessments. Following my investigator’s
concerns about the adequacy of this healthscreen, the Governor
contacted the South West Prison Service Safer Custody Adviser to
review reception, first night and induction procedures. The interim
findings were sent to my investigator and are annexed to this report.
The review found many areas in need of improvement, particularly
information sharing and communication, and made 22 recommendations
accordingly. It was discouraging that when my investigator interviewed
the Head of Healthcare, she had not been told about the review. I am
assured that the Head of Healthcare is now involved in the review
process.
71. The clinical reviewer found that the reception healthscreen nurse’s
understanding of the first reception healthscreen process might have
been undermined by the introduction of the IDTS programme two days
before. While I acknowledge that the nurse might not have been clear
about the treatment of the man’s substance misuse needs, I do not
accept that she was unaware of the importance of accurately assessing
his level of risk.
72. During the first night assessment, the induction officer said that he did
not consider the man to be at risk of self harm. He said that the man
was apprehensive, but not unusually so for someone who had not been
in prison before. The induction officer had not seen the suicide and self
harm warning form before his interview with my investigator. The officer
told my investigator that he would have opened an ACCT document if he
had seen the warning form.
73. The doctor described his assessment of the man’s mental health which
included consideration of the risk that he presented to himself. The
clinical reviewer commented that the doctor’s assessment was “in-depth”
and found that the man “did not reveal any undue anxiety or depression”.
During his interview, the doctor told my investigator that he looks around
the prisoner’s neck area as part of his assessment and specifically
recalled that there was no redness. The doctor did not consider the man
to be at risk of suicide, based on information from the healthscreen and
the man’s presentation.
74. The doctor had the man’s clinical record to inform the medical
assessment. However, he did not find the suicide and self harm warning
form. He said that his judgement would have been different if he had
seen the form and he would have started suicide prevention measures.
My investigator looked at the original clinical record as part of her
investigation. The suicide and self harm warning form was filed in a
separate, later, section of the clinical record to the healthscreen. It is
likely that the form was in that part of the record when the doctor made
his assessment. This reinforces the importance of my earlier
recommendation about recording self harm in the “Significant Events”
section of the clinical record.
75. Prison Service guidance, entitled “The ACCT Approach”, advises staff
how to recognise risk. Alcohol or drug misuse, recent suicide attempts,
and a longer sentence than expected are all things to be taken into
consideration. This was the man’s first time in prison and he was
withdrawing from heroin. He had been under constant supervision in the
court cell, hours before arriving at Bristol. I am concerned about the
reception healthscreen nurse’s assessment. I am also concerned that
the reception officer would always defer to the nurse when considering
whether to open an ACCT. I endorse the ongoing South West Safer
Custody Adviser’s review into the reception process. In the meantime, I
make the following recommendation:
The Governor and the Head of Healthcare should review
procedures and training to ensure that staff in reception effectively
consider a prisoner’s risk of suicide or self harm.
Did the man know that he would be receiving methadone?
76. The man’s family found it difficult to accept that he would have taken his
life if he had been expecting to be given methadone that night. My
investigator asked the doctor if he could remember telling the man that
he should expect a dose, but the doctor could not specifically remember
that detail of their conversation. The doctor was convinced that the man
would have expected to receive methadone following his medical
assessment. The clinical reviewer found that there was no evidence to
suggest the man was not expecting to receive methadone, but he was
concerned at the lack of documentation recording this fact. He made the
following recommendation, which I endorse:
The Head of Healthcare should ensure that details of
communication with prisoners about the likely next steps, including
medication to be prescribed, should be documented.
Was the man located in the right place?
77. As part of the investigation, my investigator contacted the Department of
Health’s section head for substance misuse. He explained that the
purpose of IDTS is the early identification and treatment of prisoner’s
substance misuse needs. IDTS was launched in 2006 and continues to
be rolled out across prisons. The first IDTS units opened in July 2007.
Bristol was in the second wave of prisons to receive funding, which was
in April 2007. Bristol therefore implemented the IDTS unit in just over a
year, which the Department of Health Head of substance misuse
described as “a fairly brisk implementation”.
78. In order to implement an IDTS service, a prison must complete a
planning tool kit. There are three main factors in respect of safer
custody in the planning toolkit for local prisons:
- There must be a dedicated unit sufficient for each prisoner to
stay on the unit for a minimum of five days.
- There must be unrestricted observation, through large
observation hatches on cell doors.
- There should be a 24 hour healthcare presence, so a night
nurse must be on duty.
79. The first night assessment and prescription is also designed to promote
safer custody. A doctor carrying out the first night assessment might
assess someone as quite comfortable, depending on the amount of
drugs still in their system. In this case, they might not prescribe
anything. According to the substance misuse lead, “if someone is
assessed as in withdrawal then they should get robust medical treatment
on their first night.”
80. The IDTS programme does not specify that all cells in the units must be
safer cells. (Safer cells have specially designed furniture and fittings to
reduce the number of ligature points.) The large treatment hatches in
the doors could be viewed as ligature points and may give prisoners
access to other points outside the cells. A judgement was made that, on
balance, larger treatment hatches on the IDTS units (that enable more
effective monitoring and the easier dispensation of medication) would be
prioritised over the eradication of ligature points. It should be noted that,
even in safer cells, ligature points cannot be entirely removed.
81. The man was located in his cell by an induction officer. It was the third
day that the IDTS was in operation and, understandably, the officer did
not know the routines for dispensing medication. Ideally, the man would
have been met by an IDTS nurse and shown to an appropriate cell.
Unfortunately, the induction officer did not know about the problems with
the treatment hatches on one side of the unit. Although the higher
treatment hatches did not entirely obstruct the view into the cell, it was
not ideal and other cells were being used in preference. The IDTS nurse
said that he was initially confused when he looked through the treatment
hatch and saw that the man was hanging. The delay was moments. I
do not think the higher treatment hatch would have affected his
treatment or the outcome of resuscitation attempts. However, I am
pleased to record that all of the doors were replaced in the month
following the man’s death.
82. When the induction officer walked into the cell with the man, he did not
notice the nail in the wall opposite the door. My investigator spoke to the
man in charge of works for Bristol, and also to the Department of Health
substance misuse lead about the responsibility to ensure that any such
unnecessary ligature points were removed from cells before the IDTS
unit became operational. Both were shocked to discover that such a nail
could remain in the cell following refurbishment work. However, it was
not clear whose responsibility it was to check each cell’s fitness for use.
Not only was there a nail in the wall, but my investigator found the cell to
be in a state of disrepair that was surprising for a newly opened unit.
83. The Department of Health substance misuse lead explained that there is
an IDTS performance management structure, with prison health
performance indicators. However, the indicators do not refer explicitly to
the physical environment of a prison because there are many other
performance measures. The only requirements in that respect are that
the IDTS unit is dedicated, the size of the unit must meet the needs of
prisoners, there should be adequate observation hatches and sufficient
healthcare staff are detailed to work overnight.
The Governor and the Head of the IDTS unit should ensure that the
physical environment in the IDTS unit is improved to reflect its
therapeutic purpose.
Did the man have the opportunity to make a telephone call?
84. The man did not telephone his family while he was at Bristol. He arrived
at the unit at a busy time, in the middle of the dispensing of medication.
He had no opportunity to telephone his family then and was taken
straight to his cell. He collected his dinner and returned to his cell. The
next opportunity for a telephone call would have been after the doctor
made a medical assessment of the man, but the unit’s regime was
running late and he was taken straight back to his cell.
85. I am concerned at the possibility that the man had no chance to speak to
his family that night. He knew that his mother was concerned about him
as it was his first time in prison. My investigator was assured by the
nurse in charge of the IDTS unit that the importance of a prisoner’s
contact with his family on the first night was understood. Efforts were
made to ensure that every prisoner had the opportunity to make a
telephone call when they first arrive in prison. Although I understand that
the IDTS unit was newly opened and its regime was unsettled, I believe
that it might have had an unacceptably damaging effect on the man’s
frame of mind that he could not speak to his mother.
The Governor and the Head of the IDTS unit should review
procedures to ensure that all prisoners have access to the
telephone on their first night in prison.
Were resuscitation attempts timely and appropriate?
86. The clinical reviewer found the resuscitation efforts to be an example of
good practice and writes that: “The resuscitation was carried out calmly
and effectively by the combined team of nurses and healthcare officers
and later with the paramedics.” I agree that staff reacted quickly to the
discovery of the man hanging in his cell.
87. I was particularly pleased to find that an OSG went into the cell and cut
the man’s ligature. Often in my investigations, Operational Support
Grade staff are reluctant to have contact with prisoners. It is to the
OSG’s credit that he was prepared to act quickly in the interests of trying
to save the man’s life.
88. I was surprised to discover that a defibrillator was not located on the top
floor of the IDTS unit, and one had to be retrieved from three floors
down. While I do not think this would have affected the outcome in this
case, I hope that consideration will be given to locating a defibrillator in
the IDTS office on the third landing of the unit.
89. The doctor requested a second defibrillator because he was worried that
the first was not working properly. In fact, the instruction was exactly the
same when he applied the second defibrillator. In his interview, the
doctor reflected that he was being over-cautious by requesting the
second defibrillator and there was nothing wrong with the first piece of
equipment. I recognise the doctor’s thorough approach in this matter.
90. In their response to the draft of this report, the family raised the following
concern:
“It is clear that the cell was locked and that permission had to be
obtained to get a key to gain access. It may well be that speed was of
the essence at that stage. The procedure for opening up a cell and
providing immediate medical help at night appears to be somewhat
unclear and does not appear to accommodate what might be, as in this
case, a medical emergency.”
In response to this concern, my investigator contacted the prison and
requested sight of any instruction to staff about the use of sealed key
pouches. The prison have a clear instruction to staff that is updated
annually. The instruction is clear that the Night Orderly Officer must be
present before the sealed pouch can be broken to access a key, to
ensure that the security of the prison at night is preserved. However,
“where there is, or there appears to be, immediate danger to life”, the
sealed pouch may be broken without the Night Orderly Officer’s
presence, but the prison’s control room must be notified by radio. The
prison has far less staff on duty at night, which makes the importance of
preserving a secure environment to manage prisoners crucial. It is
reasonable that staff should notify the central control room that they are
breaching the night state to enter a cell at night. However, it is also
reasonable that this situation was deemed sufficiently life-threatening to
break the sealed pouch.
CONCLUSION
91. The man’s short time at Bristol came at a time of change for the prison,
especially in its approach to detoxification. But that cannot excuse the
failings that this investigation has revealed. Tragically, the inadequate
reception healthscreen, incomplete communication of the man’s
behaviour at court, and a poorly prepared physical environment, meant
that little was done to safeguard him from the risk that he presented to
himself.
92. Had a properly informed assessment been made at the time, it is
manifest that the man would have been monitored and supported under
the ACCT system.
RECOMMENDATIONS
The Prison Service did not send a response to these recommendations prior
to the issuing of the final report. The Chief Executive of Bristol Primary Care
Trust, wrote to my investigator describing the recommendations as
“reasonable” and assuring her that the Head of Healthcare had already begun
to address some of the issues raised.
1. The Governor should remind reception staff of the requirement to file
a copy of any suicide and self harm warning form in the prisoner’s
core record.
2. The Head of Healthcare should remind healthcare staff completing
first reception healthscreens that all information about risk of self
harm or suicide should be noted on the “Significant Events” page of
the clinical record.
3. The Governor and the Head of Healthcare should review procedures
and training to ensure that staff in reception effectively consider a
prisoner’s risk of suicide or self harm.
4. The Head of Healthcare should ensure that details of communication
with prisoners about the likely next steps, including medication to be
prescribed, should be documented.
5. The Governor and the Head of the IDTS unit should ensure that the
physical environment in the IDTS unit is improved to reflect its
therapeutic purpose.
6. The Governor and the Head of the IDTS unit should review
procedures to ensure that all prisoners have access to the telephone
on their first night in prison.