Individual at High Down

Investigation into the circumstances surrounding the
death of a man at HMP High Down,
at hospital in August 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2010
This is the report of an investigation into the death in August 2008 of a man, a
prisoner at HMP High Down. At about 2.10am that day, he was found hanging in a
room known locally as a Listener suite, to which he had been taken so that he could
telephone the Samaritans. He was transferred to hospital where, at 11.30am, he
was pronounced dead. It was just two months before his 19th birthday. He had
been subject to formal self-harm monitoring procedures since 20 August.
I extend to the man’s family and friends my sincere sympathy and condolences for
their tragic and untimely loss.
The investigation, conducted by my colleagues, has been complex and protracted as
many issues have had to be examined. As important as it has been to ensure that
the report is accurate and thorough, I recognise that the delay in issuing it will have
added to the anxiety felt by the man’s family. I offer them my apologies for this.
As part of the investigation, I commissioned a clinical review of the management of
the man’s health needs while he was in custody. This was conducted by two clinical
reviewers. A Quality and Clinical Governance Manager at the local Primary Care
Trust oversaw their work. I am most grateful to them all for their major contribution
to the investigation. The man’s parent shave commented that the Manager’s
oversight of the review detracts from its independence. I have considered their view
carefully and am satisfied that both clinical reviewers have the appropriate
qualifications and experience to draw independent conclusions about the care given
to their son. The Manager’s role has merely been to co-ordinate and ensure that the
Primary Care Trust is fully appraised of the findings of their review.
I should also like to thank the Governor and his staff at High Down for their co-
operation and assistance. I owe special thanks to the liaison officers for their help
and to their colleagues in the Safer Custody Department who offered invaluable
advice.
The investigation has raised a number of concerns, the most serious of which relate
to the events surrounding the man’s last hours, organisational inefficiencies in the
Control Room, and the family’s initially unhappy experience of the family liaison
offered by the prison. I hope the recommendations that I and the PCT have made
will be implemented as a matter of priority, and that this will help prevent a similar
tragedy occurring at High Down or at any other prison.
At the consultation stage, the man’s parents raised a number of concerns, as well as
proposing amended and additional recommendations. I have undertaken both to
represent their personal views directly in the relevant sections of this report, and to
advise them that any further concerns they may have can be raised at the inquest
should they wish to do that. As a consequence of their concerns, I have reviewed
the report, and have made some amendments to the recommendations.
My report tells a sad story of a vulnerable young man. The man was on remand
awaiting sentence, having been arrested for having a broken glass bottle in his
2
possession. Like so many other prisoners who have taken their own lives, he had
mental health and substance misuse problems and found it difficult to cope with the
pressures of living within a closed institution.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman May 2010
3
CONTENTS
Summary
Investigation process
HMP High Down
Key Events
Issues
Principal conclusions
List of recommendations
4
SUMMARY
The man was born in October 1989. His early years were disrupted by poor health
and difficult behaviour. In 2005, he was diagnosed with Attention Deficit
Hyperactivity Disorder (ADHD). As a teenager, he became involved in the illicit use
of drugs and heavy drinking, committing acquisitive crimes to feed his habit.
He had served two previous sentences at High Down, the most recent of which was
a nine week sentence from which he was released on 9 May 2008. During that
period, he was subject to formal self-harm monitoring procedures after telling staff
he had nothing to live for.
On 7 June, less than a month after his release, he was arrested in Croydon for being
in possession of an offensive weapon - a broken bottle. He told the station sergeant
he was suffering from ADHD, paranoid schizophrenia, autism and asthma. He
claimed he was a heroin and crack user and that he drank heavily. He also said he
had tried to slit his wrists, hang himself and taken an overdose of drugs in the past.
The man was detained overnight in a police station where he was examined on
three occasions by different doctors, each of whom recorded their findings in a
Detained Persons Medical Form. One of the doctors thought he presented a high
risk of self-harm. He appeared in court the next day and was remanded in custody.
He was taken to HMP High Down near Sutton in Surrey. The Prisoner Escort
Report covering the journey between the police station and the court, and later
between the court and High Down, indicated that he had a ‘mental condition’ and
that he presented a risk of self-harm.
His presentation during the reception procedures at High Down was such that he
was not considered to be at risk of self-harm. However, the investigation found no
clear evidence to show whether the reception staff had sight of either the PER or the
Detained Person’s Medical Form, or whether they took their contents into account
when judging his risk. Neither his previous prison record nor his previous clinical
record was available during the ten week period he spent at High Down before his
death in August.
The doctor who examined the man on the day of his arrival judged that he was not
withdrawing from alcohol but did need treatment for his opiate dependency. She
therefore prescribed a Subutex based detoxification regime. Upon the completion of
a Cell Sharing Risk Assessment which concluded that he presented only a low risk
of harming others, he was placed initially in the induction unit in house block 3 and
subsequently in the detoxification unit in house block 6.
The local Counselling, Assessment, Referral, Advice and Throughcare Service
(CARATs) completed a Comprehensive Substance Misuse Assessment and drew
up a care plan for him, with his agreement, on 16 June. However, he did not attend
the sessions that were programmed for him.
In June and July, the man’s behaviour began to deteriorate. He received written
warnings about his conduct and attitude towards staff. He told staff on five
occasions that he was being threatened by other prisoners but, except in one
instance when he was assaulted, he gave no names. The investigation found no
clear evidence of the extent to which his claims were investigated.
5
On 17 August, the man told an officer that his mother had died of cancer three years
earlier, that his father had committed suicide, and that his girlfriend had also
committed suicide after giving birth to their stillborn baby. The officer later had the
presence of mind to check the facts with his father over the telephone, and found the
claims to be false. No-one from the prison thought of consulting him as to whether
he might give his formal consent for staff to inform his parents that he had self -
harmed and that Assessment, Care in Custody and Teamwork (ACCT is the Prison
Service’s system for supporting and monitoring prisoners at risk of harming
themselves) monitoring procedures had been initiated.
In the light of the man’s reported family circumstances, the officer completed a form
for his referral to the Mental Health In-Reach Team. The form was returned to the
referrer because it had not been completed correctly. This was not in keeping with
the procedures agreed within the prison’s mental health in-reach team. The form did
not reach the author until after the man had died. However, by the time he was
referred, an appointment had already been booked for him to see a Consultant
Psychiatrist.
Three days later, on 20 August, Assessment, Care in Custody and Teamwork
(ACCT) procedures were invoked after the man inflicted a minor injury to his wrist
and appeared to be in distress. Before the ACCT plan was opened, he had spoken
to Listeners (prisoners trained by the Samaritans to support other prisoners in
distress). There was a suggestion that a blanket ban may have been imposed on
him seeing Listeners as he allegedly told them stories about himself that were hard
to believe.
At about midnight on Friday 22 August, he asked to speak to a Listener but quickly
changed his mind and asked instead to be allowed to call the Samaritans using a
dedicated portable telephone provided by the prison. However, as the telephone
was already in use by another prisoner, he had to wait until it became available at
about 1.10am. As only a poor signal could be achieved in the vicinity of his cell, the
Governor had given his permission for prisoners to be taken out of their cell to make
their call to the Samaritans from the Listener suite on the landing above. He was
allowed out of his cell for this purpose at 1.17am, and arrived at the suite about a
minute or so later. At 2.10am, he was found hanging from a metal conduit in the
ceiling of the suite.
The investigation found no clear evidence that documents containing important
information about events that had occurred immediately prior to the man’s admission
to High Down on 9 June 2008 were available to reception staff or taken into account
in the process of assessing his risk. The documents included a Prisoner Escort
Record, a Detained Person’s Medical Form (from the police station), his previous
prison record, and his previous clinical record, all of which contained clear evidence
of risk of self-harm. Although there was no evidence that the absence of these
records had any significant impact on the quality of care he received at High Down, I
cannot overstate the importance I attach to the need for prisoners’ previous records
to be available at the earliest possible point of any subsequent periods of
imprisonment.
There is a significant discrepancy between the timing of some of the entries made by
an Operational Support Grade in his ACCT ongoing record regarding him moving
from his cell to the Listener suite and the unrebuttable timings shown on CCTV
6
footage. There is no evidence to prove beyond doubt that the OSG monitored him
during the 53 minutes he spent in the Listener suite before finding him hanging.
The room used as a Listener suite in house block 5 was a multi-functional facility,
not dedicated solely for use by prisoners in times of personal crisis. It was scruffy,
poorly decorated and, at the time of the man’s death, littered with ligature points and
equipment that could be used for self-harm. When my investigators inspected
Listener suites in other house blocks, they found in one a small pile of rubble left by
contractors.
It took staff in the prison’s Control Room nearly two hours to make contact with the
duty governor after the man had been found hanging. His parents were not
informed of events until four and a half hours had elapsed.
The initial family liaison between the prison and his parents was not well-handled,
and the officer in question was replaced as the prison’s FLO.
These matters, and a number of other observations and criticisms I make in this
report, need to be addressed.
Along with the PCT, I make a number of recommendations which I urge the National
Offender Management Service to accept and implement. Back to Life Ltd (a Surrey
based training company that provides resuscitation services to Community Trusts
and prisons) make nine further recommendations about the emergency response
made by staff when the man was found hanging.
I understand from the Governor that some measures have already been taken in
respect of the issues described in this report and in reports published by Her
Majesty’s Chief Inspector of Prisons.
7
INVESTIGATION PROCESS
1. The investigation was opened on 28 August 2008. On that day, both
investigators met the Governor, other senior members of staff, and a
representative of the Independent Monitoring Board at High Down, in order to
explain the nature and scope of the investigation. (Independent Monitoring
Boards are made up of local members of the public appointed by the
Secretary of State for Justice to monitor the treatment of prisoners.) The
Prison Officers’ Association were also invited to the meeting but did not
attend. On the same day, notices to prisoners and to staff were displayed in
prominent places around the establishment inviting anyone with concerns
about the man’s death to make themselves known to my investigators. No-
one came forward.
2. I also asked the local Primary Care Trust to conduct a clinical review of the
management of the man’s health needs while he was in custody. Two clinical
reviewers undertook the review. Their work was overseen by a Quality and
Clinical Governance Manager from the local PCT. Upon receipt of the PCT’s
first draft report, my investigator asked for further information. A subsidiary
report was later submitted by Back to Life Ltd.
3. Three prisoners and 35 members of staff at High Down were interviewed
formally during the course of the investigation. I am particularly grateful to the
Samaritans Coordinator for High Down, who agreed to be interviewed and to
conduct enquiries of his own in order to assist my investigators. Informal
discussions were held with three other members of staff, two of which were
conducted by telephone. (At the consultation stage, the man’s parents
expressed their view that the fact that my investigator did not formally
interview a CARATs worker at High Down represented a lost opportunity to
gather further and better information about the manner in which their son’s
Drug Intervention Records were completed. Unfortunately, although she was
interviewed, the note was mislaid.)
4. On 1 September 2008, the investigator and my then Senior Family Liaison
Officer met for the first time with the man’s parents to invite them to raise any
matters of concern about their son’s time in prison and about the
circumstances of his death. Further meetings took place on several
occasions, most often in the company of their solicitor, to provide the family
with up to date information about the progress of the investigation and to
enable them to raise further matters of concern. Amongst their main
concerns were:
• The manner in which they were treated by one of the establishment’s
family liaison officers.
• The delay in informing them of the events that occurred during the night of
22/23 August.
• The extent to which staff at High Down managed their son’s diagnosed
condition of ADHD.
• The discrepancies in timings recorded in his ACCT form during the night
of 22/23 August 2008.
• The effectiveness of the suicide prevention measures initiated for him.
• The state of the Listener suite in which he hanged himself.
• Whether he was bullied and how this was managed.
8
• The conduct of prison staff at the hospital.
9
HMP HIGH DOWN
5. Situated near Sutton in Surrey, High Down is a large local prison for adult and
young men. (Local prisons serve Magistrates and Crown Courts in their area
and hold prisoners detained before trial or shortly after conviction.) The
establishment opened in September 1992. At the time of the investigation, it
could hold up to 1,103 prisoners.
6. There are six main house blocks (residential units). House block 3 is the
induction unit. House block 6 operates as the main detoxification unit whilst
house block 4 is used as an overspill detoxification unit. There is also a
segregation unit and a healthcare centre. Healthcare is provided by the local
Primary Care Trust. The healthcare centre has beds for up to 23 in-patients.
Her Majesty’s Inspectorate of Prisons
7. High Down was inspected by the former Her Majesty’s Chief Inspector of
Prisons in May 2006. In her report of that inspection, published the following
August, she wrote:
“High Down, along with all local prisons, is under tremendous pressure as
a result of the growth in the prisoner population. Despite this, the
establishment had made considerable strides in a number of areas.
However, it was failing to ensure the safety of all its prisoners and we and
managers had serious concerns about the behaviour and attitudes of a
small number of staff. As a result, High Down is not yet the healthy prison
to which its Governor aspires. Nevertheless, it is moving in the right
direction.”
8. Where safety was concerned, the report said:
“Reception, first night and induction arrangements were good in most
respects as were arrangements for prisoners at risk of self-harm.
Prisoners resident in the segregation unit were safe and were normally
well treated. There were adequate arrangements for prisoners needing
detoxification, and levels of discovered drug use were not particularly high.
Suicide and self-harm prevention arrangements were satisfactory. The
prison had a problem with bullying by prisoners and we received
complaints of staff intimidation. There was an urgent need to improve the
handling of prisoners’ formal complaints about allegations of assault by
staff. There had been a marked over-reliance on the use of force against
prisoners and on the use of special cells, and despite some recent
improvement this remained a serious concern. Systems for protecting
vulnerable prisoners on normal location had failed and needed
overhauling. The prison was not performing sufficiently well against this
healthy prison test.”
10
The report made the following comments about the personal officer scheme:
“There was no effective personal officer scheme. Prisoners did not
generally know if they had a personal officer or who he or she was. Wing
files did not reflect the individual attention of a personal officer. The prison
had re-evaluated the personal officer scheme with a view to focusing
support on prisoners most in need. Linking personal officers to wings had
not worked, since they were commonly re-deployed around the site
because of under-staffing. Recent changes in working practices were
partly designed to keep officers in their own house blocks as much as
possible enabling more constructive relationships. It was hoped that the
more needy prisoners - those most vulnerable, the self-harming, the
dangerous - could be recognised and focused on as they arrived, or as the
need emerged. The re-evaluation was to be welcomed, in that it
recognised the value inherent in the personal officer scheme and sought
to make High Down a safer place.”
9. Where suicide prevention was concerned, HM Chief Inspector recommended
that checks by night staff on prisoners subject to Assessment, Care in
Custody and Teamwork (ACCT) procedures should be frequent and
unpredictable, and that case reviews should be attended by representatives
of all departments that have regular dealings with the prisoner.
10. The prison underwent a further, follow-up inspection in May 2009, the report
of which pointed to clear evidence of improvement. In the concluding
paragraph of her introduction to the report, HM Chief Inspector wrote:
“In spite of its considerable expansion, High Down was a safer prison
than at the time of the last inspection, thanks to considerable efforts to
tackle violence and bullying. It was now performing reasonable well in
all four of our key areas: safety, respect, purposeful activity and
resettlement. Given the pressures of a busy and expanded local
prison, this is a commendable achievement.”
11. Where safety was concerned, HM Chief Inspector wrote:
“Arrangements to deal with bullying and violence had improved
considerably. A full time violence reduction coordinator managed the
day-to-day operation of the over-arching violence reduction strategy.
The monthly safer custody meeting focussed on relevant issues and
had strong links to the security department. Information was analysed
and used to inform interventions to reduce violence. Staff supported
the use of peer supporters as anti-bullying representatives, and anti-
bullying measures were well managed by the coordinator. Allegations
of bullying were treated consistently and investigated promptly. The
number of violent incidents recorded was not excessive for the size
and composition of the population.
“There was a comprehensive suicide and self-harm prevention
strategy. A full- time suicide prevention coordinator oversaw the
protocols effectively, with input from residential managers and support
from the safer custody committee. There had been an external review
of procedures following three self-inflicted deaths since the last
11
inspection. The quality of self-harm monitoring documents was
generally good. Care mapping was effective and case managers
ensured that reviews were on time, although they should be
more multi-disciplinary. The Listener scheme was properly supported
and well advertised, and prisoner access was good.”
Independent Monitoring Board
12. In their report on High Down for the period 2006 - 2007, the Independent
Monitoring Board (IMB) emphasised the increasing range and mix of
prisoners in the establishment, some of whom they said were inappropriately
placed in a local prison. The Board also commented on the difficulties
caused by overcrowding and reduced funding. Despite this, they believed
that High Down was well run, with the vast majority of staff committed to
providing a secure, fair and decent regime for prisoners. The Board
commented that there had been particular emphasis in building good
relationships between staff and prisoners.
13. In their report on High Down for the following year, the Board drew further
attention to their concerns about the holding of a large number of young
offenders in the establishment. The Board expressed their view that the
presence of so many young offenders created an imbalance. Time, energy
and commitment had, in the Board’s view, been diverted from other areas
which had suffered. Problems had been compounded by overcrowding,
recruitment failures and consequential shortages of permanently based staff.
14. In the executive summary of their report, the Board wrote as follows:
“We consider that the prison is well managed, with a strong and
consistent theme of providing a fair and humane regime for prisoners
within a framework of security. The Board appreciates that difficult
decisions over priorities have constantly to be made. There is
determination on the part of management to target available funds and
to do the best with what it has.”
Previous investigations at High Down
15. Before the death of the man, I had investigated the death of four other
prisoners who had apparently died by their own hand at High Down. I
understand from the Governor that follow-up action has been taken in respect
of many of the issues I have raised in earlier reports.
The management of prisoners considered to be at risk of self-harm or suicide
16. The National Offender Management Service’s policies for the management of
prisoners considered to be at risk of self-harm or suicide are set out in Prison
Service Order (PSO) 2700. Governors and Directors of prisons are required
to set out their local policies in keeping with the provisions of the PSO. Below
is a brief summary of its key elements.
12
Assessment, Care in Custody and Teamwork (ACCT) procedures
17. ACCT procedures are pivotal in the management of at-risk prisoners. The
ACCT document is the principal tool for assessing, monitoring and managing
any prisoner thought to present a risk of self-harm or suicide. ACCT
procedures can be initiated by any member of staff, irrespective of grade or
discipline. The ACCT form itself contains instructions and guidance for its
use.
18. If a member of staff has reason to believe that a prisoner is at risk of self-
harm or suicide, he or she must open an ACCT form straightaway. The
following further actions must follow:
• A ‘Concern and Keep Safe’ form must be opened immediately. The
purpose of this form is to determine the main issues causing the prisoner
to be at risk of self-harm or suicide.
• An immediate action plan must be compiled within one hour of the ACCT
form being opened. The purpose of the immediate action plan is to
consider and record the most appropriate environment and regime
required to support the at-risk prisoner prior to the first case review. The
plan should be drawn up within an hour of the ACCT form being opened.
• An assessment interview must be conducted with the at-risk prisoner by a
trained assessor within 24 hours of the ACCT form being opened. The
purpose of this interview is to examine in depth the reasons behind the
risk posed by the prisoner. The details of the assessment then inform the
initial case review.
• An initial case review must be conducted within 24 hours of the ACCT
form being opened. The review panel must, in conjunction with the at-risk
prisoner, agree a care and management plan - or ‘care map’ - setting out
goals or the prisoner to achieve, with the help of staff, in order to reduce
his risk.
• Thereafter, regular multi-disciplinary case reviews must be convened,
each involving the at-risk prisoner, so that his risk can be monitored and
his care map updated.
19. The ACCT form can be closed once those involved in the prisoner’s care, as
well as the prisoner himself, are content that the risk has reduced to the point
where formal monitoring procedures are no longer necessary. However, in
such cases, a post-closure review, once again involving the prisoner and a
multi-disciplinary panel, must be convened within an appropriate interval.
The Samaritans
20. Each prison is required to engage with a local branch of the Samaritans.
Representatives of the local branch normally visit their establishments on a
regular basis in order to see prisoners who wish to consult them, to attend
safer custody or suicide prevention team meetings, and to see members of
the Listener team.
13
The Listener scheme
21. Listeners are prisoners trained by the Samaritans to help and support those
prisoners who are in distress or despair. Each prison is required to make use
of an appropriate number of Listeners. They are accessible 24 hours a day
and their interaction with prisoners is conducted in private on a confidential
basis.
22. Central to the work of the Samaritans is the very strict principle of
confidentiality which applies equally to prison work. Consequently, the details
of any conversation between a Samaritan or Listener and a prisoner will
remain completely confidential. Without this reassurance, prisoners may not
feel able to approach Samaritans and talk freely about their feelings in an
atmosphere of total trust. It is therefore important that telephone calls to
Samaritans must not be monitored or overheard.
23. It is the Samaritans’ policy that, when prisoners are considered to be
seriously at risk of suicide, they will actively encourage them to seek further
help. If the volunteer recognises that a prisoner does not wish, or is unable,
to seek help on his own, then the volunteer will attempt to gain the prisoner’s
permission for staff to be alerted to the need for help. If the prisoner
withholds consent, the volunteer will respect his wishes.
Peer support facilities
24. Annex 10C of Prison Service Order 2700 sets out the types of rooms that can
be used by those prisoners who may require peer support. These include
Listener Support Suites and Time Out Rooms. Although frequent references
to Listener suites are made in this report, that specific term is not recognised
in the PSO.
Violence reduction
25. Governors are required to have in place a local violence reduction strategy.
At High Down, the strategy seeks to deal with mental and physical bullying,
threats, fights and assaults. The Safer Custody Team, comprising key
managers, monitors a series of indicators of the level of self-harm and
bullying and meets regularly to deal with current issues and review the
strategy. Wing managers and their staff are required to investigate instances
of bullying, balancing the need both to protect victims and deal appropriately
with perpetrators. The local strategy requires that a Bully Book should be
opened in respect of any prisoner suspected of bullying. By this means, the
behaviour of the prisoner concerned is monitored for an appropriate period
and a record is kept of any sanctions imposed upon him.
14
KEY EVENTS
Background
Previous sentence
26. The man had already served two prison sentences at High Down before his
arrest on 7 June 2008. The second of the two sentences was imposed on 10
April 2008 after he was found guilty at Magistrates Court of theft, battery and
failure to surrender to bail. He was given a nine week sentence which
expired on 9 May.
27. On 1 May, the following entry was made in his clinical record:
“Seen in houseblock 2 at the request of CARATs [Counselling,
Assessment, Referral, Advice and Throughcare service]. On examination,
patient appears to be very low in mood and tearful. Has a history of
deliberate self-harm. Self-harmed when he was here in December 2007.
“Very polite, compliant, good eye contact. No symptoms of psychosis.
Appears to be a bit depressed.
“States that he wants to end it as he has nothing to live for. Has been
living on the streets for the past 2 years and will have nowhere to live
when he leaves prison.
“Plan: 1. ACCT opened
2. To be moved to a sharing cell
3. To see GP as an emergency tomorrow
4. Dr to prescribe Nytol [a medication normally
used to help patients sleep] for 3 days.”
28. The clinical record does not make clear if or when the ACCT form was closed.
Neither the clinical record nor the core prison record was available to the
reception staff at High Down when the man was received there for a third time
on 9 June 2008. (No system was in place in the National Offender
Management Service at the time of his death to allocate the same prison
number to a prisoner at the outset of each new sentence. A new prison
record was therefore opened every time a prisoner was received anew.
However, a system known as p-NOMIS has since been introduced that allows
for the allocation of the same prison number to each prisoner continuously.)
Arrest on 7 June 2008 and subsequent police detention
29. In the early hours of Saturday 7 June 2008, the man was arrested for being in
possession of an offensive weapon - a broken glass bottle. He was detained
at a police station where, at approximately 4.00pm that day, he was formally
charged. He remained in police custody over the weekend.
30. A comment was made by the station sergeant on a risk assessment form to
record that the man said he had a sore neck, suffered from epilepsy, and had
ADHD, autism and asthma. He also said he had paranoid schizophrenia and
was addicted to crack cocaine and heroin. He told the sergeant he had tried
15
to slit his wrists, hang himself, and had taken an overdose in the past. He
was interviewed by a doctor for 15 minutes from 1.37am. The doctor
recorded that he was under the influence of drugs and was not fit for
interview, charge or transfer. He prescribed 30mg of Dihydrocodeine (an
analgesic normally prescribed for moderate to severe pain) three times daily,
and recommended that he should be subject to half hourly checks.
31. At 9.00am that day, the man was seen in the police cells by a doctor who
noted,
“… hears voices, self harm never, sectioned, no delusions, some
paranoia, sleepy, heroin yesterday, overdose hanging electrocution,
sleepy, reassess at 10.30.”
The doctor recorded that he thought he presented a medium risk of self -
harm. He, too, considered him to be unfit for interview. He saw him again at
10.50am. On this occasion, the doctor recorded that he was less drowsy and
could cope with being interviewed. However, he thought his risk of self-harm
was high.
32. The doctor saw the man yet again at 2.46pm and noted, “appears well, 2
bags heroin smoked a day, appears calm, declines dhc [Dihydrocodeine] see
fme [forensic medical examiner] if unwell later”.
33. Another doctor assessed the man in the police cells at 2.17pm and noted:
“… was diagnosed with Schizophrenia, drugs abuser, DSH [deliberate self-
harm] - old cuts and cigarette burns on left arm. Drinks alcohol heavy at
times. Now complains of withdrawal from drugs.”
He deemed him to be fit for transfer and interview, and prescribed further
dosages of Dihydrocodeine.
34. During the day, whilst in the custody suite, the man was assessed by a
representative of the Croydon Branch of the Westminster Drug Programme
who completed a Drug Intervention Record (DIR). He told the assessor that
he suffered from paranoid schizophrenia, manic depression and Attention
Deficit Hyperactivity Disorder (ADHD). He also reported that he used crack
and heroin daily, having last done so the day before (6 June). The DIR was
faxed to High Down prison on 11 June.
35. At 10.15pm, another police doctor saw the man and wrote in the Detained
Person’s Medical Form:
“Paranoid schizophrenic, seen for review as requested. See previous
records. Reports to be epileptic/ADHD as well as heroin addict: £250 a day.
Now suffering from stomach cramps, diarrhoea and vomiting. Also painful
toes right foot from bus running over it 3 days ago - Thursday. Cold numb
very tender right foot, 1st and 2nd toes. Discoloured: purple/red. Last had
Dihydrocodeine 2x30mg at 18.23. Transfer to hospital for further
management. Alert and orientated and co-operative.”
16
36. The man was transferred to hospital for treatment to his foot later that night
and returned to the police station shortly after 2.00am the next day. The
following note was made by a doctor in the Detained Person’s Medical Form:
“The man is on 10mg of Temazepam [normally prescribed to help
people sleep] and 30mg of Dihydrocodeine – quantity 2. This seems
to have been prescribed following arrest as he was found to have a
foot injury and was taken to hospital to have it looked at following
arrest - no fractures, just soft tissue injuries.”
Appearance in court
37. The man was taken from the police station to the Magistrates Court during the
morning of 9 June. The Prisoner Escort Record (PER) covering the journey
shows that he was thought to have a ‘mental condition’. Also noted was that
he presented a risk of escape, self-harm and substance misuse.
38. At court, he was remanded in custody and ordered to appear at the same
court on 30 June. He left for HMP High Down shortly before 6.00pm. The
PER for the journey does not indicate what time he arrived. The form
contains comments about a risk of self-harm and escape. Other entries
indicate that he was an epileptic and a paranoid schizophrenic.
HMP High Down: 9 June – 22 August
Reception health screen
39. As part of the normal reception procedures at High Down, the man underwent
an initial health screen conducted by a bank nurse. He told her he had no
fixed address and had not registered with a doctor. He said he had been in
High Down earlier in 2008. He added that he had received no injuries during
the previous few days but that, although he had not been prescribed any
medication, he was using an asthma inhaler.
40. The man told the nurse he usually drank five large bottles of cider daily and
the last time he had done so was on 6 June, the day before his arrest. He
admitted he had taken heroin the same day and said he usually took heroin to
the value of £250 daily. He added that he also used cocaine and crack and
sometimes took drugs intravenously.
41. He said he had not received treatment or medication from a psychiatrist but
had been diagnosed as a paranoid schizophrenic. He said he had self-
harmed in January 2008 by cutting his arm but did not currently feel suicidal.
The nurse decided to refer him to a doctor in relation to his substance misuse
history.
42. My investigators attempted to interview the nurse on several occasions.
However, each time an appointment was made, she failed to appear. Thus it
has not been possible to check with her whether she had sight of the PER
covering the man’s journey from court to High Down. Neither did the
investigation find any clear evidence to show whether the information
contained in the Detained Person’s Medical Form was available to her.
17
Reception interview
43. An officer interviewed the man in reception in his role as First Night in Prison
officer. At interview, he explained that newly received prisoners would be
interviewed initially by a reception officer who would sign the PER to show it
had been seen. However, the investigation found that the PER was not
signed by any member of staff at High Down. He told my investigators that
he could not remember whether he saw the form.
44. During his interview with the officer, he said he had last harmed himself in
January 2008. When asked how often he would self harm, he said, “every
day for three years”. In answer to the question, “Are there any triggers or
reasons why you would self harm or commit suicide?”, he said, “Being locked
up with someone I don’t like”. However, he said he had no plan to take his
own life. During his interview with the officer, my investigator asked him if he
had any reason to believe he was at risk of suicide. The officer replied that
had he felt he was at risk, he would have opened an ACCT plan, inferring that
he did not judge that he was at risk when he met him.
45. The man told the officer he had been discharged from High Down six months
earlier. (In fact, as I have said above, he was released from High Down on 9
May 2008, a month previously, at the end of a nine week sentence.)
Cell sharing risk assessment
46. The purpose of the cell sharing risk assessment is to measure what, if any,
risk a prisoner presents of harming others if he were to share a cell. Another
officer carried out the man’s assessment in her role as a reception officer. A
nurse, whose signature is illegible, conducted the healthcare element of the
assessment. (The nurse was probably the bank nurse.)
47. At interview, the officer told my investigator she had not seen the PER form.
However, she signed the cell sharing risk assessment form to confirm that
she had received it. She also confirmed that she had not seen his Detained
Person’s Medical Form.
48. The officer noted on the cell sharing risk assessment form that the man told
her he was ‘detoxing’ and wanted to be placed on a detoxification
programme. He also said he wanted to be allocated to a single cell or to the
segregation unit. He emphasised that he did not want to be allocated to a
shared cell. She noted that he had a history of drug and alcohol misuse and
was currently dependent on both. She recorded that he was not currently
subject to ACCT procedures and there was no evidence that an ACCT form
had been opened for him previously. (As his records relating to his previous
period of imprisonment at High Down were not available to her or anyone else
at that time, she would not have known that he had been subject to ACCT
procedures during that sentence.) She concluded that he presented a low
risk of harming others and therefore considered him suitable for sharing a
cell.
49. The nurse who completed section three of the form concluded that he
presented a low risk of harming others and that there were no concerns about
18
self-harm risk. The nurse wrote, “For houseblock 4 or houseblock 6 for detox.
Fit for ordinary location.” (House blocks 4 and 6 both operated as
detoxification units.)
50. The man was allocated to house block 3 that evening. His record does not
make clear whether he was put into a shared cell or a single cell. At the time
of the investigation, house block 3 was the induction unit. The following
morning, he was moved to a single cell in the detoxification unit in house
block 6. During the induction process he was not thought to be at any risk of
self-harm.
Appointment with a prison doctor
51. At approximately 9.00pm that day, a prison doctor saw the man as part of the
reception procedures. At interview, she told my investigators:
“I wrote [in his clinical record] that the man was an 18 year old male. I
documented that he told me he had last been in High Down a month
previously and that time he had been in High Down for nine weeks. I
asked him what treatment he’d had for substance misuse during that
period and he said he hadn’t had any treatment. He told me that over the
previous four weeks he’d been taking heroin, 200 pounds a day which he
was smoking and he’d last smoked it three days previously. I said that
he’d had DF118s [another term for Dihydrocodeine] over the weekend,
presumably that was in the police station. He told me that he used crack,
£200 a day which he smoked and also alcohol. He consumed five three
litre bottles of nine per cent cider a day. He’d last drunk alcohol three
days previously. He told me that he started drinking on waking and that
he drank all day. In his past medical history which I asked him about, he
said he was asthmatic and he was treated with salbutamol and becotide
100 inhalers. In the psychiatric history I asked him about, he told me he
was diagnosed with paranoid schizophrenia when he was ten years old
but he’d had no treatment or follow up for it. I found his mental state to be
appropriate with no sign of psychosis. He exhibited signs of opiate
withdrawal and I also documented that he hadn’t had any
benzodiazepines [normally prescribed for symptoms of anxiety, sleep
disorders, agitation, alcohol disorders] in the police cells. This is because
if people were alcohol dependent and they were given benzodiazepine in
the police cells for treatment of it, then they might not show signs of
withdrawal when they came in and, as he hadn’t had alcohol for three
days, then I concluded that he wasn’t using alcohol in a dependent
manner. We did a urinary drugs screen and this was positive for morphine
(that’s heroin), positive for benzodiazepines, positive for cocaine, negative
for methadone and negative for amphetamines. And we agreed that he
would be prescribed a subutex regime which is treatment for substitution
for heroin or other opiate addiction - withdrawal state.”
52. She explained that, as she felt he was not withdrawing from alcohol, she
believed he needed treatment only for his opiate dependency. She said:
“We have a standard regime we start with. Normally if people come in on
heroin, we don’t make long term plans in their treatment in reception. So I
19
start off a treatment plan and that would be reviewed by a key worker, by
his nurse in the subsequent days.”
53. When asked where the treatment plan was documented, she replied,
“Well the initial one was for the subutex regime and the nurses in the
following days would have seen him. I know there is some documentation
but the plan would be in the notes. I know there aren’t many and I don’t
know if a plan would have been made certainly verbally but whether it’s
written down or not I don’t know because quite, not uncommonly we don’t
have access to the IMRs [Inmate Medical Records]. It’s quite a big prison
now and they go missing and we would write on continuation sheets if we
can’t find them. So I don’t know if it wasn’t documented or if it wasn’t on
the continuation sheet.”
54. When asked what the process would be following the reception health screen,
she said:
“He’d be followed up by a nurse in liaison with a CARATs [Counselling,
Assessment, Referral, Advice and Throughcare] worker and a treatment
plan would be formulated, however simple or complex, and it would be
presented to me to write a prescription if the nurse and CARATs worker
was happy.”
55. The doctor said he made no mention of being on Ritalin or of suffering from
ADHD for which Ritalin is sometimes prescribed. She could not remember
whether he may have displayed signs of ADHD when she saw him. When
asked whether a detoxification programme might have had an effect upon him
if he was suffering from ADHD, she said she thought it might. However, she
said if he had been displaying such signs, she would have discussed this with
him and with the mental health in-reach team.
Appointment at Wellman clinic
56. Shortly after the man’s consultation with the doctor, he underwent a Wellman
(a general health) assessment by a Healthcare Assistant (HCA). At interview,
she described him as being “very pleasant to talk to” and “very chatty”. She
explained that she was not conducting a mental health assessment of him,
and said she had become involved in assessing him because he had been
placed on a detoxification programme.
57. During the consultation, he told her he had been taking Ritalin prior to his
imprisonment because he had ADHD. When asked whether she would
normally refer to the mental health in-reach team any prisoner suffering from
ADHD, she said:
“No, the reason I say that is because the mental health in-reach team
really do specify that they deal purely with very severely psychotic
symptoms. They don’t deal with depression or anything like that because
they feel that if, for example, they have a substance misuse worker or a
CARATs worker, the CARATs worker can deal with that but I wouldn’t
refer someone with ADHD.”
20
58. My investigator asked the HCA what could be done to help and support
prisoners with ADHD. She replied:
“Aside from the medication, I’d just make sure that there was always
someone making other people aware but then it’s something that the
nurses would have picked up on as well.”
59. She decided to refer the man to a doctor for his asthma. She could not
remember whether, at the time of her consultation, he appeared to be under
the influence of drugs or withdrawing from them. However, she was clear that
she did not regard him as being subdued, emotional, depressed or suicidal.
Appointment with substance misuse lead nurse
60. The substance misuse lead nurse saw the man on 10 June in order to give
him his medication for the day.
61. At interview, the nurse told my investigators he had met the man during his
earlier sentence at High Down. He said he knew he had not been subject to
any detoxification treatment in the community prior to his arrival at High Down
on this occasion. He described him as a very quiet person who would give
only short answers to any questions asked of him.
62. The nurse said 10 June would have been the second day of the man’s
detoxification programme and explained that he would have been prescribed
8mg Subutex, a medication that had to be administered under supervision
rather than being held in possession. The medication came in tablet form and
was held under the tongue until it dissolved. According to the nurse, it was
thus impossible for him to store the medication. He told my investigators that
the first five days of the detoxification regime were normally used to stabilise
the prisoner, during which period an initial 4mg dosage would be given.
Thereafter, the dosage was increased daily by 2mg for five days. The nurse
said that, during this period, the CARATs staff and those who ran Wellman
clinics normally worked together with the prisoner. According to him, each
prisoner was asked at the end of the five day period whether he wished to be
placed on a maintenance programme or remain on a detoxification regime.
He said the man chose the former.
63. My investigator asked the nurse to confirm whether individual entries were
normally made in a prisoner’s clinical record on each occasion he was seen
by a substance misuse nurse. He said that this would normally be the case.
He acknowledged that no entries had been made in the man’s clinical record
until 27 June.
Referral to Counselling, Assessment, Referral, Advice and Throughcare
Service (CARATs)
64. At the time of the investigation the CARATs manager at High Down explained
to my investigators that all CARATs clients were automatically seen by the
CARATs team as part of the induction process. (The man had already been
a client of this service in the community and was therefore an existing client.
As noted at paragraph 35 above, a community based CARATs worker
completed a Drug Intervention Record (DIR) in respect of him whilst he was in
21
police custody. This was forwarded to the prison on 11 June.) A member of
the Substance Misuse Team at High Down at the time updated the DIR on 11
June. During this assessment, the man said he had taken an overdose of
valium in February 2007 as a suicide attempt and had made six previous
attempts at suicide. He also told him that his foster sister had died from a
heroin overdose three weeks earlier.
65. The member of the Misuse Team asked him to sign a consent form allowing
the information on the DIR to be shared with a range of internal and external
agencies. A signature appears at the bottom of the consent form, indicating
that he had given his consent. The initials ‘CP’ also appear in a number of
boxes on the form listing which agencies could be given the DIR and which
could not. The initials are written neatly, in a form of handwriting that seems
different from that seen in his signature. This was a matter of concern to the
man’s family. My investigators asked the member of the Misuse Team if he,
rather than the man, had entered the initials on the form. He confirmed that
neither the dates / times nor the initials shown on the form were in his own
handwriting. My investigators were satisfied that the man had entered his
initials himself and that there was no evidence of any wrongdoing on the part
of the Misuse Team member. However, the man’s parents remain doubtful
as to whether it is his signature.
66. On 16 June, the man was interviewed by his allocated CARATs worker at
High Down, in order to complete a Comprehensive Substance Misuse
Assessment. The purpose of this assessment was to identify what his
substance misuse needs were and to draw up a care plan for him. At the
conclusion of the assessment, he was asked to sign a consent form. The
following words were written at the end:
“I have been told by my worker that all the agencies listed above will
respect the confidentiality of any information about me and that individuals
will not share this information with their parent organisation except for the
purpose of ensuring the continuity of my care.”
67. Two signatures can be seen at the bottom of the consent form. One of the
signatures is that of the CARATs worker. The other purports to be the man’s
signature. However, it differs from his signatures that appear elsewhere in his
CARATs file. This, too, was of concern to his family. One of my investigators
discussed this matter with the CARATs worker to check the authenticity of the
signature. She confirmed that she entered his name in the box reserved for
the prisoner’s signature. She said she did so because, during her interview
with him, he did not pay attention to what she was saying and behaved in an
odd fashion. She told my investigator that such was her concern at his
behaviour she wondered at one stage whether to terminate the interview. As
with the DIR mentioned in paragraph 53 above, the initials ‘CP’ appear in a
number of boxes on the form listing which agencies could be given
information contained in the Comprehensive Substance Misuse Assessment
form. She confirmed that she had entered them on his behalf after confirming
his consent with him during the interview. My investigators were satisfied that
there was no evidence of any wrongdoing on her part.
22
Substance misuse summary and care plan
68. At the conclusion of the man’s assessment form, the CARATs worker
summarised his physical and mental health needs as follows:
“No concerns with physical issues. Client states that he does not wish to
take medication connected with his mental health. Client states he wants
to feel normal. He wants to feel and be in control of himself.
“Work required to explore relaxation techniques to attend and participate
IDTS [Integrated Drug Treatment System] relaxation session.”
69. She agreed the following care plan with him:
Objective How achieveWhat workWho will doIn what timescale?Comments on
will be meas be done towork? completion/reason
achieve th objective not achi
objective?
Explore relaxatio Feedback an Attend and CARATs an 14 July 08 DNA (Did not attend
techniques discussion poparticipate [the man
group in IDTS
relaxation
techniques
Increase knowle Feedback an Attendand CARATs an 14 July 08 DNA
and awareness - discussion poparticipate man
healthy living an group healthy livi
healthy balance and health
balanced d
Increase reinforc Increase mot Attend and CARATs an 14 July 08 DNA
motivation to chaand moveme participate man
ambivalence the stage of IDTS MET
change [Motivation
Enhancem
Therapy]
Explore issue aroIncrease Attend and CARATs an 14 July 08 DNA
crack knowledge anparticipate man
awareness arIDTS crack
crack use awareness
Explore relapse Increase Attend and CARATs an 14 July 08 DNA
prevention strat knowledge/ d participate man
awareness of IDTS relap
triggers/copinprevention
strategies session
70. The CARATS manager told my investigators that, in order for the man to
achieve the objectives listed in his care plan, he would have been required to
attend a group session related directly to the subject matter described in each
objective. When asked whether there were a number of group sessions that
would have been programmed to take place by the target date set for him (14
July), she confirmed that within the IDTS programme there were 14 group
sessions. Thus, within a 28 day period, each session would be run twice.
She commented that, in relation to the IDTS relaxation group objective, he
had two opportunities to attend. In fact, he attended neither.
23
71. The man’s CARATs file contains his CARATs case history, a form on which
entries can be made by individual CARATs team members to record specific
details of significant events and interventions. My investigators noticed that a
number of entries were made on his form, one of which on 27 June was,
“Went and saw the man. No problems. Awaiting IDTS groups”. The entry
was initialled by the CARATs manager.
Seen by Nurse Adechi
72. On 27 June, a Registered Mental Nurse made the following entry:
“The man is currently on 6mg of Buprenorphine tablet which seems to be
quite sufficient for him. He however complained of being constipated and
is being prescribed Lactulose commencing from 28 June 08.”
73. At interview, the nurse explained that he appeared to be alright other than in
respect of his constipation. She said:
“He would have been definitely ok because things like that I pick up
because I’m a mental nurse. Sometimes you don’t need to see it at all. I
can read body language, check their eyes ... I do call ‘you appear not to be
yourself today, is there anything going on?’ But that day there was nothing
at all that I could see was wrong.”
Written warnings
74. On 20 June, an entry was made in the man’s file by a nurse to record that he
had been abusive by blowing cigarette smoke in his face. The nurse told him
that a red entry, or written warning, had been made in his file. On 29 June he
pressed his cell bell to demand that an officer ask his cell mate to light a
cigarette for him. The officer refused to do so and told him he had been given
a further red entry.
75. He was required to return to court on 30 June. Little is recorded in his prison
file about this. Upon his return to High Down, he returned to the detoxification
unit in house block 6.
76. The next day (1 July 2008), a Senior Officer (SO), the then manager of the
detoxification unit, had cause to interview the man as he had received the two
red entries described above. She told my investigators that, whenever a
prisoner received two such warnings within 28 days of each other, the unit
manager was required to interview him to decide what if any further action
was required. She decided to warn him that, if he were to receive a further
written warning within that period, he would be referred to an Incentives and
Earned Privileges (IEP) Board at which his position on the IEP scheme would
be reviewed. (The IEP scheme has three levels: basic, standard and
enhanced. Prisoners’ behaviour and attitude inform decisions made by
officers and managers as to what level of the scheme they should be placed
on. Each level attracts a different range of privileges such as access to
television and entitlement to visits and letters. At this time, he was on the
standard level.)
24
Seen by substance misuse key worker
77. That same day, a nurse made the following entry in the man’s clinical record:
“Seen this afternoon. Has lots of anger issues and problems with
authority. Have discussed attending groups to address these issues –
reluctant at first but finally agreed. To have subutex increased to 8mg as
from 3 July. Then review after court appearance. To return to group
when up and running.”
78. My investigators interviewed the nurse. She explained that she was a band 6
nurse with Registered General Nurse training. (The band relates to the level
of responsibility defined in the job description and the pay level it attracts. A
band 6 nurse is relatively senior.) She said she had been appointed as a key
worker in the establishment’s substance misuse team and explained that this
role required her to act as a liaison point between her clients and the CARATs
team. She told my investigators:
“We came round to the fact that he does have problems with people telling
him what to do. He doesn’t like being told what to do. So I just broached
the subject and said there’s a new group that will be up and running soon
... would you be happy to attend it because I think you would benefit from
it. At first he didn’t want to attend but by the time we’d finished our chat he
was quite happy to try it.”
She explained that the group she had mentioned to him was a community
based psychotherapy group held in the prison each Tuesday.
79. When asked how he appeared when she saw him, she said:
“He was fine. I think he’d had a visit that day or the day before. His mood
was ok. There was no cause for concern at all. We discussed his
Subutex being increased and I said to him, once you’ve been to court we’ll
review it depending on your sentence, because I think he was looking at a
quite a long sentence.”
Alleged assault by another prisoner
80. At approximately 4.00pm on 4 July in cell 61B11 (i.e. house block 6, first
landing, B spur cell 11) the man pressed his cell bell. When Officer A
responded, he told her he had been attacked by another prisoner. He said
the attack was related to a tobacco debt. He told the officer he had been
punched on both sides of his head. She recorded in his file that she had seen
red marks on both sides of his temple. Whenever a prisoner sustains an
injury other than through self-harm, a form F213 must be completed. (Where
the injury is caused by an act of self-harm, a form F213 SH must be raised.)
The form should be completed by the member of staff who first discovers the
injury. The investigation found no evidence that this form was completed on
this occasion. At interview, the officer told my investigators she would
ordinarily complete the form in such circumstances but was not certain that
she had done so. Neither could she remember whether she told anyone
about the assault.
25
81. The officer said:
“If he had open wounds or anything like that, I would automatically get
Hotel Two to come and attend. [Hotel Two is the radio call sign used by
whichever member of the healthcare team is responsible for providing the
first response to a prisoner who may need medical attention.] In this case,
because we have nurses based on our house block who deal solely with
those people that are on detox, the likelihood is I would have asked one of
those nurses to take a quick look at him. But I don’t remember which I
did.”
82. When asked what the local anti-bullying policy required her to do, the officer
said:
“We are supposed to go and inform the senior officer. We should make an
observation book entry and he should be interviewed as to what’s
happened. And if it’s found that there is what we think to be bullying going
on, then the person who is alleged to have committed the assault would
be placed on a Bully Book.”
83. My investigators were told that Bully Books were an important feature of the
establishment’s anti-bullying strategy. Staff were required to open one
whenever they had reason to believe that a prisoner was a victim of bullying.
Bully Books were used to monitor prisoners’ behaviour and to ensure that
appropriate measures were taken to safeguard victims and to tackle
perpetrators. The investigation found no evidence that a Bully Book was
opened on this occasion.
84. In interview, the officer offered the view that the man may not have ingratiated
himself with other prisoners because he may have frequently asked others to
give him items such as tobacco, sugar and tea bags.
Discovery of minor cut and improvised weapon
85. The officer made a further entry in the man’s prison file later that day. She
wrote:
“At approx 19.20 hours he pressed his cell bell to tell staff he had a paper
cut! Hotel two attended and put a plaster on it just to keep it clean. I then
had a chat with him and he gave me an improvised weapon (a toothbrush
with a melted head with one razor blade in it). He said it was purely to
protect himself. He is worried he will now be labelled a grass.”
(The term ‘grass’ is prison slang for an informer.)
The man moved to a different house block
86. The following day (5 July), the man was moved to house block 4 after telling
staff that other prisoners had threatened him. He offered no names of the
individuals allegedly involved. Officer A explained that one of the spurs in
house block 4 was for prisoners subject to a detoxification regime which was
probably why it was chosen for him. This explanation was supported by an
entry made in his prison file by another member of staff on the day he moved.
26
The officer, whose signature is illegible, wrote that ‘meds’ were the reason for
him being moved there.
87. The officer told my investigators:
“From what I can remember there was another prisoner in the man’s cell
when he reported that somebody had assaulted him. He was trying to get
the other lad to say that he’d seen it happen and that what he was saying
was the truth. The other lad wasn’t willing to say anything and he didn’t
want to get involved, even though the man had called him his cousin.
Later, when he wasn’t around, the other prisoner came to me and said,
Can I have a word? I said of course. And he said the reason I didn’t want
to say anything was because that’s not what happened.”
88. When asked whether the prisoner told her what actually happened, the officer
explained that he had told her it was the man who had entered another
prisoner’s cell and intimidated them. In turn, the other prisoner had felt it
necessary to defend himself.
89. My investigators were presented with an extract from a staff observation book
in which the following entry was made on 5 July:
“A Bully Book has been opened on this prisoner [name withheld]. His
sanctions are not to enter other prisoners’ cells and also stay on the 1st
landing unless collecting medication or posting mail etc.”
90. My investigators found no evidence to show whether the decision to move the
man was the result of a formal investigation into his claims that he was being
threatened. Neither were they able to clarify whether the decision to open a
Bully Book in respect of the other prisoner took into account the possibility
that the man, rather than he, may have been the aggressor.
91. My investigators asked the officer whether his behaviour was symptomatic of
ADHD but she said she did not know.
Further written warning
92. On 9 July, he was issued a further written warning for misusing his cell bell.
Abuse of subutex
93. The man was supposed to report to the treatment room each day to collect
his medication - Subutex - from a member of the detox team. On 13 July,
Nurse A was on duty in the treatment room. When she realised he had not
reported for his medication, she asked a colleague to collect him from his cell.
He refused to attend. She therefore decided to see him in his cell. At
interview, she said she asked him whether he had a problem or if he was ill.
He told her that other prisoners were asking him to give his tablets to them.
She told my investigators that it was possible for prisoners to hide their
Subutex tablets in their mouth rather than swallowing them so that they could
store them or pass them to other prisoners. However, the substance misuse
lead nurse told my investigator that prisoners could not store subutex
whenever a prison officer was in attendance with the nurse who was
27
administering the medication. (Although these tablets are dissolvable, my
experience of other investigations has shown that prisoners can be innovative
in finding methods of storing such medication for illicit use.) He told the nurse
he had refused to go to the treatment room in order to avoid being
compromised. She said she drew attention to this development at the weekly
multi-disciplinary substance misuse team meeting.
94. According to the nurse, he did go to collect his medication the next day. She
said he did not appear to be anxious on that occasion. She told my
investigators:
“When he was in house block 4, he wasn’t really chatty, he kept himself to
himself. But when I came up to house block 5 he was more open. We
chatted and he told us about what he had been doing. He had formed a
sort of friendship with another prisoner across from his cell, who
sometimes when we go there to give him his medication he’s usually in
the prisoner’s cell talking. So he was quite pleasant really and I remember
the last day because I along with another nurse went to give him the final
0.4mgs of Subutex and he was saying ‘Oh miss, I’m so glad to be off this,
drug free and alright’. And I did say to him that if there were any side
effects or if he was having any ill effects from not having tablets, he should
contact one of the nursing staff to get him a symptomatic treatment.”
95. The nurse told my investigators she was not aware that he may have been
suffering from ADHD and did not know anything about the condition.
CARATs case history update
96. On 14 July, the CARATs worker made the following further entry in the man’s
case file:
“Client is no longer IDTS. He stated that he has been moved to house
block 4. Client is currently on 8mg subutex maintenance.”
Refusal to return to his cell
97. At about 7.25pm on 17 July, the man was required to return to his cell in time
for the evening roll check (head count). Instead, he took hold of the railings
on his landing and refused to let go. Consequently, he was forcibly removed
by staff using authorised control and restraint (C&R) techniques. (C&R are
authorised techniques designed to minimise the use of force necessary to
prevent a prisoner from harming himself or others or to restore order. They
involve the use of wrist and arm locks applied by teams of three trained
officers.) He was taken to the segregation unit where he was placed on a
disciplinary report for disobeying an order from a SO to return to his cell. He
was issued with a notice of report telling him that his case would go before a
disciplinary hearing on 19 July.
98. The use of force forms completed by staff on his arrival in the segregation unit
show that he had been injured whilst being restrained. A Form F213 was
completed by a staff nurse after examining him. The nurse recorded that he
complained of pain in his right knee and that some swelling was evident. The
nurse applied an ice pack to the affected area.
28
99. The nurse also completed a segregation safety algorithm, the purpose of
which was to assess the man’s ability to cope with being segregated. The
nurse considered that he would be able to cope with a period of segregation.
The duty governor countersigned the completed algorithm to confirm that he
agreed with the assessment.
Disciplinary hearing
100. An entry made in the man’s core prison record on 18 July refers to his
relocation from house block 4 to a single cell in house block 5. The Governor
later explained that he was allowed to calm down in the segregation unit that
day before being located on house block 5 and then went from the house
block to the segregation unit on 19 July for his adjudication (disciplinary
hearing). The Governor believed that this was a good practice that ensured
that prisoners were held in the segregation unit pending an adjudication only
when there were good grounds for them not being held in a house block.
101. He appeared before the Governor on 19 July in regard to his refusal to return
to his cell two days earlier. He pleaded guilty but, in responding to the
charge, he told the Governor he had refused to return to his cell because
another prisoner had accused him of being a “grass”. He added that the
prisoner told him that if he did not leave his cell he would be given “a good
kicking”. He said he tried to speak to the SO (whose order to return to his cell
he had disobeyed) but the SO would not listen to him. When asked by the
Governor how long the conflict with the other prisoner had lasted, he said,
“Three or four days and on Thursday afternoon he said I’d get a kicking. It
was about 4.30pm.”
102. He was found guilty of the charge and given a punishment of 28 days
stoppage of earnings and 21 days forfeiture of privileges, but both penalties
were suspended for a month. This meant that the punishment would not be
put into effect if he committed no further disciplinary offences during that
period. It also meant he could return to a house block. My investigators were
presented with no clear evidence to show whether his claims of being bullied
were investigated, or whether the information he gave during the disciplinary
hearing was communicated to staff in his house block.
Further appearance in court
103. On 21 July, the man appeared at Magistrates Court for a further hearing. He
returned to High Down the same day. His record contains no information as
to the outcome of his court appearance. The PER for the journey to court
includes the comment, “Didn’t want to go in a holding cell with others”.
29
CARATs case history update
104. The man’s CARATs case history form was further updated on 27 July with the
following entry by the CARATs worker:
“Client states he wants to switch to methadone. This has been discussed
with the detox team. Client is in contemplation stage in cycle of change.
Referral made to MET [Motivation Enhancement Therapy] group. Activity
form completed.”
Abusive to staff
105. On 4 August, the man swore at a nurse who was administering his Subutex
medication. A note of the incident was made in his record.
Appearance in court
106. On 11 August, the man appeared at Magistrates Court. He was remanded in
custody and ordered to appear before the court again on 26 August by video
link. The remand warrant issued contains the following explanation:
“Remand after conviction for the purpose of enabling enquiries to be made
or of determining the most suitable method of determining the case.”
He returned to High Down that evening.
The man moved for his own protection
107. An entry made in the man’s prison file by a nurse on 14 August shows that
the man had been threatened that day by a number of prisoners. A decision
was made to move him to another part of the house block for his own
protection. The next day, the following entry was made:
“Upon speaking to him today, he raised concerns regarding a previous
incident with another inmate. He feels that now [name withheld] has been
moved off the house block, we shouldn’t be keeping him segregated from
the rest of the house block. I explained we were doing this for his own
safety. The SO will speak to him in the morning.”
108. At interview, the nurse explained that the man’s segregation took the form of
being kept in his cell except at meal times when he was allowed out on his
own solely to collect his meals. She said whenever prisoners claimed they
were being bullied, staff were required by the local anti-bullying policy to open
a Bully Book in respect of the prisoner(s) found to be perpetrating the bullying
and to monitor events. When asked why it was necessary to keep him
segregated despite the fact that the alleged perpetrator had been moved to
another house block, she said it was necessary to do so in case there were
other prisoners involved in bullying him. She said he was ‘fine with that’.
109. A note was also made to this effect in the man’s security file but the following
additional information was included:
30
“[The prisoner – name withheld] refused an order to move house blocks
after threatening to assault him. [The prisoner – name withheld] was
issued with an IEP 3 for his behaviour. When returning to his cell [the
prisoner – name withheld] said, “I’m gonna do that c*** one way or another.
I know where he lives on the out and I’ve got a lot of cousins on this spur
who I will tell to beat him up as well, you watch and see gov.” [The
prisoner- name withheld] was moved to HB4 and placed on basic regime.”
110. SO A was acting in the role of unit manager of house block 5 at the time. She
spoke to the man on 16 August and made the following record of her
conversation with him:
“I have spoken to him this morning and he does not want to move. He has
stated he doesn’t feel threatened on HB5. I have explained that staff have
concerns for his safety, but he stated that he feels safer on HB5. I am
confident I have explained the options available to him. He has signed to
say he wants to stay on HB5.”
111. At her interview, she was not clear about precisely what form his segregation
took but thought that “in general terms” it probably meant he was “kept behind
his door” (in other words kept in his cell).
112. When asked why he was keen to remain on house block 5, the SO said:
“We spoke about that. He spoke about where he had been previously and
he didn’t want to go back to sharing a cell. He was very keen to have a
single cell and he was saying this was the safest he’d felt. He was looking
around the room. I got the impression he felt that it was a secure place to
be.”
113. The Governor later explained that in his view house block 5 had the highest
quality accommodation in the prison and was generally a sought after
location. He added that the man may have declined an offer to move to house
block 2 and that staff were flexible in listening to him before making a decision
as to where he should be located.
114. The Governor also emphasised that in house block 5 the cells are fitted with
privacy locks, which allow prisoners some control over when they can leave
or enter their cell. The Governor explained that it would thus have been
possible for the man to remain in his cell and to choose for himself when to
leave it without staff having to unlock or lock his door.
115. When asked what anti-bullying measures should have been taken, the SO
replied:
“It’s quite comprehensive. It would require basically finding out who the
perpetrators are. If we can’t find out who the main perpetrators are, we
look at the best way of resolving it. We would place them on Bully Books
to monitor them. Oft times they would be relocated. We wouldn’t as a
practice relocate the victim because then it’s not resolving anything. It’s
not showing the perpetrators are the people doing something wrong. I
previously opened Bully Books on house block 5 on four people and
managed to send each of them to different house blocks so that they
31
weren’t together, because they’d been acting as a group. It’s a little more
difficult when you don’t know the perpetrators to deal with and if the
person who is alleged to have been bullied isn’t willing to speak with you
about it that makes it more difficult.”
116. One of my investigators put to the SO that two prisoners had come forward
either just before or just after the man’s death to tell staff they thought he had
been bullied. She said she could not remember this taking place but she did
recall speaking to a Listener who saw him. She remembered him saying
words to the effect: “The kid’s off his head, I don’t believe anything else he’s
telling me now”.
117. My lead investigator wrote to both of the prisoners in order to ask them if they
were willing to be interviewed. Neither responded.
118. However, my investigators were able to interview the Listener in the presence
of the local Samaritans co-ordinator. He said he had been a Listener in
house block 5 since the unit was opened about a year earlier. He first met
the man when Officer B asked him to speak to him. He said the officer told
him he was the only one who “could sort this out”. He explained that the
officer was concerned about what the man was telling him. He therefore
spoke to him in private in his cell. (As noted earlier, the details of
conversations between a Listener and his client are confidential. Thus, it was
not possible for my investigators to ask him to disclose what was said when
he saw the man. However, he told them he saw him on two further occasions
as ‘follow up’ meetings.)
Referral to In-Reach team
119. On 17 August, the man told Officer B that his parents, child and partner had
all died within the previous three years. My investigators interviewed the
officer. He told them he had worked at High Down for just over four years.
His job currently entailed working in B spur of house block 5 where the man
was located. He said he got to know him quite well despite the fact that he
was not his personal officer. He gave the following account of the events of
17 August:
“This was the second time I had met him. I was working on B spur. We
were locking up or getting them out for exercise and it’s exercise or bang
up as we call it and people who don’t want exercise get locked behind
their doors. I noticed that his cell wasn’t very clean so I started speaking
to him with regards to cleaning his cell. Also his personal hygiene wasn’t
the greatest. So I was talking to him trying to get him to clean his cell so
what I suggested was that while everybody was out on exercise I would
get a cleaner to give him some cleaning materials to clean his cell out. I
went back some time afterwards and he told me that he’d cleaned his cell
but it still wasn’t very good. So again I asked him to clean his cell out for
his own personal hygiene. I left him to it and again sometime later I can’t
remember how long but some time later I went back again and it still
wasn’t very clean. So I took the mop myself and I showed him how to
mop his cell out. I actually ended up mopping his entire cell whilst talking
to him. And this is where he started to tell me about his parents. He
initially told me his mum had died of cancer three years beforehand and
32
that his dad committed suicide a week later because of that, because of
the stress and emotions. At this point, when he told me that his mum had
died, I had an instant connection with him because I too have lost my
mum through cancer. So because of that I sort of took him under my wing
to keep an eye on him and try and help him out.
“I took him to get some clean bedding and clean clothing so he could
chuck everything out of his cell and start afresh, a new clean cell, new
clean clothing, new clean bedding. I was going to help him get a job. And
it was when we were getting the bedding that he then proceeded to tell me
that after his mum had died that he ended up living on the streets and met
a girl who he got pregnant. He then told me that the baby was stillborn
and two months after that his girlfriend committed suicide because of it. At
that point, I asked him if he had ever had counselling and he told me he
hadn’t. So I told him I was going to try to get him some help in the form of
bereavement counselling and that is why I referred him to in-reach.”
Minor act of self-harm
120. A nurse was called to house block 5 on 19 August as the man had reportedly
scratched his wrist. The nurse made the following record:
“… made a slight scratch on the inside of this left wrist - very superficial.
No action other than soap and water to clean the scratch. Claimed he had
taken Ibruprofen 200mg x 12. Called Poisons Unit - well below toxic level
but may experience some G.I (gastro-intestinal) disturbance. No action
needed at this time.”
121. Despite the fact that PSO 2700 makes it clear that an ACCT plan must be
opened whenever a prisoner harms himself, the nurse did not do so.
122. On the same day, SO A wrote in the man’s record:
“A prisoner approached me and said he had some concerns about the
man. This was related to the fact that he states he has lost his family, who
have all passed away.
“I went to speak to him with an officer and he told us he did get upset
during the night, thinking about his family who have died. He stated he
had no current thoughts of suicide.”
ACCT opened
123. On the afternoon of the following day - 20 August – the SO did decide to open
an ACCT form as she was concerned about the man. Whenever an ACCT
plan is opened, staff are required to complete the following tasks:
• Complete a Concern and Keep Safe form as soon as possible after the
risk has been identified.
• Complete an immediate action plan.
• Carry out an ACCT assessment interview.
• Conduct a first ACCT case review within 24 hours of the initial concern
being raised.
33
• Draw up a care map.
Concern and Keep Safe form
124. The purpose of this form is to determine the main issues which are causing
the prisoner to be at risk of self-harm. The form should be completed as soon
as possible after the risk has been identified. The SO completed this form at
1.45pm on 20 August. Its full details are shown in the table below:
What are the concerns? Ask the individual open questions to determine w
the main problems are. Then tick all the relevan
boxes and give details in the open box below.
1. Suicide attempt or statem The manrecently spoke to a Listener and an off
intent to kill self regarding feeling upset and sad.
2. Self injury or statement of Yes
to self-harm. He also attempted to cut his arm resulting in a m
3. Unusual behaviour or talk scratch. He has stated that his parents are both
and his girlfriend committed suicide. He also sta
4. Very low mood (e.g. withdYes
he lost his baby.
slowed down).
5. Problems related to
He told me he made the cut on his arm because
drug/alcohol withdrawal
back was hurting. I advised him to speak to the
6. Other concerns, including
and complete a medical application.
vulnerability to age or maturit
Immediate action plan
125. The purpose of the immediate action plan is to consider and record the most
appropriate environment and regime required to support the prisoner at risk
prior to the first case review. The plan should be drawn up within an hour of
the completion of the concern and keep safe form. Whilst interviewing the
man, prior to completing the immediate action plan, Officer B told him that he
was going to telephone his next of kin. He asked him who his next of kin was,
because he had previously told him that his father was dead. He told the
officer that his next of kin was his foster father and that the telephone number
on the computer record was wrong.
126. The officer rang the telephone number on the man’s computer record anyway
and spoke to his father. According to information his father later contributed
via his solicitor, he told the officer that his son was not telling the truth about
his family circumstances, that he was a compulsive liar and that he suffered
from ADHD. He told the officer that his son had received some assistance for
his ADHD in the past, but that he needed more help. The officer told him that
he had referred his son to the mental health in-reach team. However, he did
not tell him that his son had self-harmed or that ACCT procedures had been
initiated. In order to be able to disclose this information, the officer would
have had to gain the man’s formal consent to do so.
127. At interview, the officer told my investigator that he thought he had the man’s
implicit consent to ring his next of kin but he did not tell him why he wanted to
make the call. The officer noted the details of his telephone conversation with
the man’s father in the ACCT plan but omitted to make any reference what his
father had said about the diagnosis of ADHD.
128. In the light of the man’s reported family circumstances, the officer decided to
submit a referral form to the mental health in-reach team for him to be
34
assessed. However, the form was returned as it had not been properly
completed. In line with the mental health in-reach team procedures, the form
should not have merely been returned. Instead the administrative assistant
should have telephoned or emailed the officer to obtain missing information.
Regrettably, the returned form did not arrive back at source until after the man
had died.
129. The SO and officer drew up the following immediate action plan for the man
at 4.20pm on 20 August:
Immediate actionAction By whom Completed
required
Location Feels safe on HB5 in a The SO –needs to be appr
cell. by HC for single cell. (This
done on 21 August)
Frequency of staff 3 conversations daily. Spur staff
support Minimum of 3 obs night
(NB this was entered o
front cover of the ACCT
for all users to see.)
Phone access Samaritans phone offe Officers
Listener access Has been using ListeneFacilitated by Listeners
Other immediate Support for drug proble CARATs
interventions Claims he used crack
outside.
ACCT assessment interview
130. The assessment interview should take place within 24 hours of the initial
concern being raised. The interview with the man was conducted at 3.15pm
on 21 August by Officer C who recorded the following comments:
“He had back pain which was making him feel low. He feels alright now.
He cut his left wrist several times (superficial). Attempted hanging about
seven months ago. Attempted overdose 2 days ago. He has no suicidal
thoughts or intentions. He doesn’t want to kill himself.
“He has boys of 2 years and 1 year six months. Gets on well with older
sister. Really wants to work doing anything so can have time out of cell.
Just wants a job to focus attention on. Needs to see a doctor about his
back pain. Would be fine if he had a job and saw a doctor.”
131. At interview, the officer told my investigators that she did not know the details
of the injury he inflicted upon himself that led to the opening of the ACCT plan
the day before. She had not seen a Form 213SH (report of an injury
sustained by a prisoner through self-harm). She said she was one of a
number of trained ACCT assessors. She explained that she currently worked
in the segregation unit. She said that on 21 August she was the duty
assessor and was therefore required to interview him, although she hardly
knew him. My investigators asked her to describe his approach to the
assessment and she said he spent most of the time laughing. He gave her
the strong impression that he did not take the interview seriously. She said
she found it very difficult to help him focus on her questions and to believe the
answers he gave. She said she was not aware of any attempt by him to
35
overdose on drugs two days earlier and could not verify whether he had
attempted to hang himself seven months earlier.
132. My investigators asked the officer if she knew anything about ADHD. She
said she was aware of the condition but did not know very much about the
symptoms. My investigators gave her some examples of the symptoms and
asked her if she thought he displayed any of them. She said some aspects of
his behaviour were similar to those symptoms, such as not paying attention
when being interviewed. She said that after the interview she spoke to SO A
about what she had recorded.
133. My investigators put the same question to Officer B and he confirmed that he
knew what ADHD was. When asked whether he thought the behaviours the
man manifested may have been symptomatic of ADHD, he said he felt unable
to pass judgement.
Initial ACCT case review
134. The purpose of the initial case review is to assess the risk of self-harm and to
establish a care and management plan, or Care Map. It should take place
within 24 hours of the initial concern being raised. The SO convened this
review at 6.05pm on 21 August. An officer attended, as did the man. No
member of the healthcare team was present. The review was summarised as
follows:
“No thoughts of self harm at the moment. He states he is still in a lot of
pain with his back and it is stopping him from sleeping at night. He has
applied for employment. Advised to use the Samaritans phone if he
needs support. Has been using Listeners.”
Care map
135. The following care map was agreed at the review:
Issues Goals Action required By whom and wheStatus of ac
Back pain Reduce pain Medical application The man Done
Needs a job to Find suitable Complete applicatioThe man ASAP
occupy his mind employment employment
Has cut himself Stop cutting Speak to spur staff, Spur staff as requir
when upset Samaritans or List
136. The care map did not record that the man had been referred to the mental
health in-reach team or the need for intervention by CARATs as identified in
the immediate action plan.
137. The panel considered that the man’s risk of self-harm was low. The next
case review was scheduled to take place on 28 August. The panel decided
that staff should record three conversations with him each day and that he
should be checked three times during each night. The record shows that
these targets were met.
138. My investigators were given a copy of the following email sent on 20 August
by a Samaritan to two Senior Officers about the man:
36
“While the local Samaritans coordinator was on HB 5, there was an
incident involving a prisoner [the man]. It seems he has been misleading
the Listeners who are getting fed up with him as he lies to them. He has
alleged that his parents are dead. But apparently Officer B has spoken to
them at home! Please could you get a message to Chaplaincy not to
phone his home tomorrow as the officer has already done so. The officer,
who is now on leave for 2 days, would like this prisoner referred to the In
Reach Team as he obviously has mental health problems and needs help.
I understand it has been agreed that he will be given the Samaritans
phone instead of calling the Listeners out. Someone has seen him so I’m
sure he will be able to let you know what exactly has been going on.”
139. At interview, one SO thought the sender of the email was the then Head of
the local Samaritans branch. He confirmed that the decision to offer the
Samaritans phone to the man as an alternative to speaking to a Listener was
made by the Samaritans themselves.
140. The following entries were made in the ACCT ongoing record on 21 August at
the times shown below. The signatures in the ACCT ongoing record against
each entry are illegible.
9.45am:
“I have spoken to the man this morning. He said he has a bad back and
that he is seeing a doctor next week. He also said he was feeling ok and
had no other problems.”
12.20pm:
“He collected his lunch meal. He appears in reasonable spirits but
mentioned his back again. I told him to see the doctor to get some pain
killers. He said I am, Miss.”
2.20pm:
“At roll check all was well. He had started to clean his cell and told me he
was feeling ‘fine and well’.”
7.00pm:
“Interacted well with the other prisoners on association. When spoken to
at locking time he was happy and looking forward to watching the
Olympics.”
Events during the night of 21/22 August
141. Officer D, who was the assistant night orderly officer during the night of 21/22
August, told my investigators that the man asked to speak to a Listener that
night. He said an officer told him the man used to ask for a Listener every
night and might have been abusing the system. The officer nevertheless
went to his cell and opened the door. He asked him to confirm that he
37
wanted to speak to a Listener and he said he did. The officer discovered that
his cell was extremely dirty and smelly. He therefore told him that he should
clean his cell. Although he was a little rude to him, he agreed to do so. The
officer said he then searched him and allowed him to see a Listener.
142. My investigator asked the officer whether, in view of the frequency with which
the man had been asking to speak to Listeners, he was aware of any ‘blanket’
ban on his access to them. The officer told my investigator he was aware but
believed he insisted that he should nevertheless be allowed access to a
Listener.
Events on 22 August
143. On Friday 22 August, the following further entries were made in the ACCT
ongoing record:
11.00am:
“Asked to see the man to fit him for a single cell. He states he has no
thoughts of self-harm. He states he only cut his arm due to frustration with
back pain. He now has medication and states he will not cut.” (Nurse)
11.10 am:
“He asked if he could clean his cell as he needed something to do. I
asked him how he was feeling. He stated all was well.”
4.00pm:
“Interacted well with other prisoners whilst on association. Seemed in
good mood and had good eye contact with me. No problems at this time.”
Events during the night of 22/23 August
144. On duty in house block 5 during the night of 22/23 August were two
Operational Support Grades (OSGs). OSGs are auxiliary staff who carry no
responsibility for the direct management of prisoners. By night, they are
required to be present in each house block to maintain the security of the
prison. They are not normally permitted to unlock cells except in an
emergency, when they can access a cell key kept in a sealed pouch attached
to their uniform belt after being given authority by the night orderly officer.
However, OSGs are required to conduct observations of any prisoner subject
to ACCT procedures and to draw the attention of the night orderly officer to
any concerns that might require a member of staff to enter a cell.
145. Whilst OSG A was a relatively experienced member of staff, having worked
exclusively as a night patrol for the previous eight months, OSG B was
deployed as a night patrol the first time at the beginning of that week.
146. In charge of the prison was the night orderly officer (NOO) – who had the
radio call-sign Oscar 1. (The term ‘call-sign’ refers to the coded identification
attributed to each member of staff using a UHF radio whilst on duty.) He was
supported by the assistant night orderly officer, Officer D - call-sign Oscar 2.
38
A number of prison officers were also on duty, but deployed to a central area
of the prison in case there was an incident or an emergency.
147. At interview, OSG A told my investigators that his shift began at 8.00pm. He
said it was usual to have a discussion between the staff on the evening shift
and the night staff about events of the day. The handover, he said, also
included a check of the Staff Observation Book (in which staff can record
details of issues relating to individual prisoners for their colleagues on other
shifts to read). He said he saw the Staff Observation Book when he started
his shift but there were no entries relating to the man. He initially said he
could not remember whether he was subject to ACCT procedures. He told
my investigators, “I just can’t remember if he was on an ACCT because he
was put on an ACCT that week so I can’t remember what day it was.” He
was asked how he would know how often a prisoner subject to ACCT
procedures had to be observed during the night. He explained that ACCT
forms were kept in unit offices so that staff could easily identify them and
ascertain, at the beginning of their shift, how often each prisoner had to be
observed.
148. The front cover of the man’s ACCT form clearly shows the requirement for
him to be checked three times during each night. The investigation found that
the OSG made three entries in his ACCT ongoing record during the night of
22/23 August.
OSG A’s first entry in ACCT form – routine check of the man
149. The first entry was made against a time of 8.30pm. This read, “Checked,
okay, no issues raised”. The OSG confirmed at interview that before making
this entry, he talked to the man and that he seemed perfectly alright.
OSG A’s second entry in ACCT form –the man’s request to speak to a Listener
150. OSG A’s second entry was made against the time of midnight as follows:
“Checked, ok. He pressed ECB [Emergency Call Bell]. Requesting
Listeners”. The OSG explained to my investigators that he had responded to
the cell call alarm. (All that an OSG is permitted to do in such circumstances
is to approach the cell door and talk through it to the occupant.) According to
the OSG, the man said to him, “Gov, can I have a Listener?” The OSG said
he passed this request on to the assistant night orderly officer by radio,
saying words to the effect, “Oscar 2, for information, a Samaritans phone or a
Listener required on house block 5.” When asked if he saw a Listener, the
OSG said the night staff (i.e. the assistant night orderly officer and officers
who may have accompanied him) went to see him and he changed his mind.
151. My investigators interviewed Officer D, the assistant night orderly officer, and
asked if he recalled being told that the man wanted to see a Listener that
night. The officer said he thought he did make that request. He explained
that it was a very busy night when a number of requests were made by
prisoners to speak either to a Listener or to the Samaritans. He said that, in
such circumstances, there was a need to prioritise the requests, taking into
account factors such as whether the prisoners asking for the facility were
young offenders or adults, and whether they were subject to ACCT
39
procedures. He said that he would normally give priority to those for whom
an ACCT form had been opened. He also said:
“If my Listeners are out with someone else, I will say to the OSG, offer him
the Samaritans phone or stay with him there and have a chat with him
even if he’s swearing at you, just stay there.”
Request to speak to the Samaritans
152. Officer D told my investigators he was accompanied by another officer when
he went to speak to the man in his cell. The officer remembered that he very
quickly changed his mind about speaking to a Listener and instead asked to
use the Samaritans phone. (This is a portable telephone, normally held on a
wing office, and solely for use by distressed prisoners who wish to speak
confidentially to the Samaritans.) He explained to him that he could not use
the telephone straightaway because it was being used by another prisoner.
The investigation found that this was indeed the case and that the other
prisoner left the Listener suite a few moments before the man entered it.
153. The officer explained that when he entered the man’s cell he asked him if he
wished to use the Samaritans telephone. He confirmed that he did. He then
saw him pick up a cigarette and lighter from the floor. He told him he could
not smoke in the Listener suite and he threw down the cigarette and lighter.
He asked him if he had anything in his pockets and he said he did not. He
described him as being “funny” with him when he gave him his reply. The
officer told my investigators he was thinking of searching him but, as he
thought he was a little angry, he did not want to be “too confrontational” and
so decided against conducting a search.
154. The officer allowed him to leave his cell and, in the company of the other
officer, escorted him to the Listener suite on the landing above. He walked
behind him and the other officer walked in front of him.
155. Closed circuit television (CCTV) facilities are available in house block 5 as an
aid to staff in monitoring the movement of prisoners, especially by night. A
camera is located at one end of the landing on which the man was located
and there is another on the landing above, near the unit office. My
investigators were able to view the CCTV footage recorded on both cameras
for the night of 22/23 August. Together, the two separate cameras showed
him being released from his cell at 1.17am and arriving at the suite on the
landing above about a minute later.
156. As the man reached the top of the stairway that leads to the upper landing, he
folded his arms and stooped very slightly forwards. The CCTV footage shows
a bulge in the left sleeve of his pullover as if there was something concealed
there. The officer said he did not see anything to suggest he was hiding
anything on his body. He also confirmed to my investigators that neither the
man nor he engaged in any conversation as they approached the Listener
suite. At that point, he fetched the Samaritans telephone from the nearby
office, took it to him, and locked him in the room. It is not clear whether the
CCTV monitor in the office was watched by anyone as the man came into
view. Neither officers searched the Listener suite before allowing him to enter
the room.
40
157. My investigator asked the officer whether at any stage he considered allowing
the man to use the Samaritans telephone in his cell. He said he did not
because he knew that the signal reception for the telephone in house block 5
was especially poor on one side of the building. He said that, as a result, the
usual practice was to allow any prisoner located in that area of the building to
call the Samaritans from the Listener suite where the signal was reliable. He
also cited another reason for taking prisoners to the Listener suite. He said
that some prisoners had been abusing the system by using the Samaritans
phone in their cells to charge up their own mobile phone batteries or to call
people other than the Samaritans. He explained that using the Listener suite
had reduced the level of abuse as prisoners believed they would be
monitored more closely.
158. After they had locked the man in the Listener suite, both officers left the
house block in order to resume their other duties.
OSG A’s third entry in ACCT form - discrepancy in timings
159. The man’s ACCT form contains a further, final, entry by OSG A against the
time of 2.00am on 23 August. He wrote, “Samaritans phone requested @
(sic) 0200”. This comment was at odds with the timing shown on the CCTV
footage which clearly showed that he was allowed out of his cell to use the
phone at 1.17am, some 43 minutes earlier. At his initial interview, the OSG
reiterated that it was 2.00am when the man was issued with the Samaritans
phone. At that stage, my investigators had not studied the CCTV footage and
so had no reason to question the timing of the OSG’s entry. As a result, the
timing described initially by him led them to believe that the man was only in
the Listener suite for about ten minutes before he was found hanging.
However, after viewing the footage at a later stage, my investigators
recognised the significant discrepancy. They therefore re-interviewed the
OSG.
160. At his second interview, the OSG was invited to view the CCTV footage so
that he could see for himself the timings shown. He was then asked to
account for the discrepancy and to explain why he recorded in the man’s
ACCT form that he asked for the Samaritans phone at 2.00am. The OSG
replied that he believed 2.00am was the correct time because that was the
time at which he started a pegging round. (Pegging is the term for an
electronic record of the times when staff patrol their areas of responsibility as
well as the route they take. See further explanation below.) He was adamant
that the entry was made contemporaneously. When asked how sure he was
that the man was only in the Listener suite for ten minutes before he was
found hanging, he replied that he could not say. However, he remained of the
view that the timings he recorded in the ACCT form were correct as he said
they accurately reflected the times when he checked him. He told my
investigator, “I am adamant that it was two o’clock” (when he asked for the
phone).
161. In light of the evidence the OSG offered at his second interview, my
investigators decided to re-interview Officer D. Prior to his second interview,
the officer was invited to view the CCTV footage for himself. During his
interview, he acknowledged the significant discrepancy between the time
41
recorded by the OSG and the times shown on the CCTV footage. He
confirmed that he did not have a clear memory of the chronology of events
but thought that the time the man was allowed out of his cell was likely to
have been at about 1.00am. He acknowledged that the timings shown on the
CCTV footage were highly unlikely to be wrong.
162. As a consequence of the officer’s confirmation, my investigators decided to
interview the OSG for a third time. They did so on 15 January 2009. On this
occasion, they put to him that the evidence gained from interviews was not
consistent with his evidence about the timings and offered him a final
opportunity to account for the discrepancy. He said:
“I may or may not have put down the correct procedures in his [the man’s]
ACCT form because at that time in the morning I’m tired. I could have put
him down at two o’clock as a genuine error. That’s all I can say.”
163. My investigators suggested to the OSG that the entry he made in the ACCT
form was wrong. This time, he agreed. This removed any doubt about the
fact that, as shown in the CCTV footage, the man left his cell for the Listener
suite at 1.17am rather than at 2.00am. As he was thus in the Listener suite
for far longer than originally thought (some 53 minutes rather than ten), my
investigators were concerned to check with the OSG the extent to which he
monitored him, especially whilst he was in the Listener suite.
164. At a fourth interview conducted on 12 March 2009, my investigators asked the
OSG at what times he checked him. He replied as follows:
“The first was at 8.30pm on 22 August when I came on shift. I looked in
his cell. He was awake and I spoke to him. He said he was ok. The
second was at midnight, when he rang his cell bell and asked to speak to
a Listener. I spoke to Officer D, the assistant night orderly officer that
night. He said he would sort it out. The man seemed ok to me. My third
and last check was going to take place at the end of his conversation with
the Samaritans or at 3.00am. I like to do my ACCT checks when I do my
pegging.”
Pegging
165. During one of the interviews conducted with the OSG, he told my
investigators he carried out his pegging rounds “on the hour, every hour”. (In
order to ensure that key areas of a prison are effectively patrolled throughout
the night, a pegging system is utilised. This system is usually electronic and
requires night staff to register at predefined intervals and locations throughout
the prison. The system is auditable and forms a part of the final night state
report.) He was asked whether he carried out any pegging on the lower floor
of house block 5 between 1.17am and 2.10am on the night of 23 August
2008. He replied as follows:
“No. Pegging starts from approximately 1.00am and lasts for
approximately 15 minutes. During this time, I have to peg throughout the
entire unit [i.e. all six landings]. This policy is written down in local orders.
We are given a copy of these when we start our shift. I pegged from
approximately 1.00am that night to approximately 1.15am. I did the whole
42
house block. This included the landing on which the man was located as
well as the landing on which the Listener suite is located. After I had
finished, I answered a cell call alarm from him at about 1.17 am.”
166. The OSG could recall that the man was the only prisoner on B spur of house
block 5 who was subject to ACCT monitoring that night.
The man found hanging
167. The OSG explained that at 2.00am, he began his pegging round again. He
said:
“So at two o’clock, started my pegging. He [the man] was on the
Samaritans phone that time. So I did my first site, A spur, probably takes
seven minutes, do the [point] right at the end, A spur on the ones. Come
up and do the one by the office on the twos and then go and do the threes
on the threes landing right at the end. So I come back, speaking to the
other OSG about, can’t remember what that was about. And then at eight
minutes past, nine minutes past, walked past the Samaritans - Listener
suite on B spur and I saw him hanging.”
168. The OSG could see through the window in the door that the ligature was
made from a piece of torn bedsheet tied to a metal conduit (a pipe protecting
material such as electric wiring) fixed to the ceiling. He used his radio to send
a “code 1” alert to the Night Orderly Officer. (This code alerts staff to the
discovery of a life threatening emergency without using distressing terms that
might be overheard by other prisoners.) He also asked permission to break
the seal on his pouch which contained his emergency keys, so that he could
enter the room. Having been given permission to do so by the night orderly
officer, he entered the room accompanied by the other OSG. He asked her to
get her anti-ligature knife out. As she did so, he lifted the man up so that the
other OSG could cut away the ligature. Together, they laid him on the floor
inside the suite. He had urinated. The OSG said in interview that he checked
him for signs of life. He told my investigators he checked the carotid pulse
and found none. He said his eyes were fixed and “pointing up to the sky”. He
described him as pale but warm. He said there were no signs of rigor mortis.
169. He asked the other OSG to fetch a first aid bag from the office (a matter of a
few metres away from the Listener suite). He then began to administer
cardiopulmonary resuscitation (CPR) to the man. He said that by the time he
did so “all the other crew had turned up”. By this he meant the prison’s
healthcare staff. He explained that during the brief time he was applying CPR
on his own, he applied only chest compressions. He could not recall what
rate of compressions he applied. He said that the speed at which the Ambu
bag (used for the manual application of oxygen) was brought to the suite was
“pretty quick”. When asked to confirm whether the application of mouth to
mouth resuscitation might have been quicker, and to explain what the other
OSG was doing while he was applying chest compressions, he said:
“I can’t remember. I know she was just standing there. I think she went
off to have a – she went outside ‘cos the night staff went off, went to a
different spur instead of coming to B spur.”
43
170. The OSG confirmed that, when he was joined by a member of the healthcare
team, he initially continued with the chest compressions while his colleague
used the Ambu bag, and then took over the Ambu bag himself. He said the
man did not respond to these measures. He thought the nurse was the first
member of the healthcare team to arrive at the Listener suite. He said he
stayed in the Listener suite until the paramedic crew arrived about five
minutes later. He thought the orderly officer would have given directions to
the control room staff to call for the ambulance. (The control room log
records a request for an ambulance at 2.10am and the arrival of an
ambulance at 2.18am.)
171. During her interview, OSG B told my investigators she had been deployed to
work for a week of night duties for the first time in house block 5 at the start of
the week commencing Monday 18 August 2008. She did not think she had
received adequate training for her duties, citing suicide prevention including
ACCT procedures, opening a sealed emergency key pouch, using an anti-
ligature knife, first aid, responding to cell bells and the use of Staff
Observation Books as examples of subjects in which she had not been
trained.
172. OSG B said she began her shift at 8.00pm. She said she played no part in
any events involving the man prior to 2.10am when OSG A discovered him
hanging in the Listener suite. She confirmed that he called out to her at that
point, and asked her to use her anti-ligature knife to cut the man down while
he took his weight. She thought that he may possibly have stood on a table
or chair to tie the ligature to the conduit in the ceiling and then jumped off.
173. She confirmed that she helped her colleague to lower the man to the floor but
that she did not help to administer first aid. She said:
“Afterwards I thought and during, if I was first aid trained then I could have
helped a bit more but obviously I wasn’t and I didn’t know what I was
doing, so I didn’t want to hurt him any more.”
174. She also said that, although she would not have been able personally to
check for signs of life, she thought she could see none in him. However, she
also thought someone said there was a weak pulse. After about two minutes
of entering the suite, she left to answer a telephone call in the office.
175. The members of the healthcare team who arrived at the Listener suite
included an officer together with two nurses. My investigators interviewed the
two nurses. They felt it unnecessary to interview the officer.
176. Nurse A said he was a registered mental nurse and had a degree in forensic
mental health nursing. He said that, although he was an agency nurse, he
had been working at High Down on a daily basis. On the night in question, he
was working in the detox unit in house block 6. He said he heard the coded
alarm call on the radio and went straight to house block 5. He did not take
any emergency equipment with him because he was “waiting for [call sign]
Hotel 2 to come along”. (Call sign Hotel 2 normally carries the responsibility
for taking appropriate specialist medical equipment to the site of an
emergency.) He said that when he arrived at the Listener suite he saw the
man lying on the floor, with “two or three officers” near him. They included
44
OSG A, who was administering CPR, and Officer D who was at the head. He
remembered seeing a ligature on the floor. He took over CPR and the officer
applied oxygen through the ambubag. He said he and the OSG shared their
CPR tasks until Nurse B arrived (on call sign Hotel 2).
177. At interview, Nurse B confirmed that he was in the healthcare centre when he
received the coded alert call on his radio. He said he collected a first aid box
and ran to house block 5, taking about three to five minutes to complete the
short journey. He said that amongst the first aid equipment he took with him
were “bandages, glycogen and medicine, blood pressure machine”. He
explained that he did not take any oxygen with him because this was
available in a “resusc bag” on each unit. He also said he took a defibrillator
although he noticed that a “resusc trolley”, including such equipment, was
already in place in the Listener suite when he arrived.
178. Nurse B told my investigators that when he arrived in the suite, he could see
“somebody lying on the ground being attended by officers and then my
colleague from the detox team”. He confirmed that the colleague to whom he
was referring was Nurse A. He said he was concerned to check that an
ambulance had been called and was told this had already been done. He
then assisted with the administration of CPR. He could remember seeing two
officers and Nurse A in attendance, helping with CPR.
179. Nurse B later made the following entry in the man’s medical record:
“Received a code red call to attend HB 5. The man was lying on the floor
in the Listener suite on B spur. CPR was being carried out on him by
officers and healthcare staff. Immediately asked for a call out for
emergency service. He appears unconscious but had a weak and feeble
pulse on examination. B/P 45/32 PI I5 [i.e, his pulse rate] sats 69 [i.e. his
level of oxygen saturation - described as very low]. Defibrillator was
immediately applied whilst CPR continues. Emergency service staff
arrived and took over. He was taken to hospital. There was a mark round
his neck. According to officers he was found hanged and feet above floor
level in the Listener suite. He was making a call to the Samaritans.”
180. The nurse confirmed that he checked the man’s carotid pulse using a
sphygometer, an instrument that measures blood pressure. Having detected
a weak pulse, he continued with CPR until the paramedics arrived. He also
confirmed that the defibrillator advised not to shock.
181. Officer D also played a part in managing the emergency. At interview, he
said he took about 20 seconds to reach the Listener suite in house block 5
once he had received the coded alert on his radio. Upon arrival, he saw OSG
B outside the room and OSG A inside on the floor near the man who was
lying face upwards. The officer described him as having wet trousers. He felt
his pulse and told my investigators that OSG A did not seem sure about what
he should do. He said the OSG was not administering CPR to the man when
he first arrived. However, he said to him, “Come on, we can’t lose him.”
Thereafter, according to the officer, the two of them began CPR. He said he
asked the other officer to fetch an ambubag. He had difficulty recalling which
of them used the ambubag but he confirmed that he applied chest
compressions.
45
182. The officer thought that the time lapse between the OSG finding the man
hanging and his own arrival at the Listener suite was about 30 seconds. He
also thought that the time lapse between his arrival and the application of
CPR was at most ten seconds. He guessed that it took Nurse A a minute or
two to arrive and five to six minutes for Nurse B to reach the suite. He
thought it may have taken the other officer a minute or two to fetch the
ambubag.
183. One officer submitted the following statement to explain his actions in
response to the emergency:
“I took over from OSG A on the oxygen bag to release him from the scene.
Approx 5 minutes after using the oxygen bag myself and another officer
were released to escort the ambulance on to the scene. Paramedics then
took over from staff and carried out further CPR and tests and took the
man to hospital.”
184. The other officer confirmed in her statement that she checked the man’s left
wrist to see if there was a pulse (although she does not mention whether she
found one). She later left to escort the ambulance from the gate to the house
block, accompanied by the other officer.
185. Further emergency first aid was applied by the paramedics in the Listener
suite. At 2.48am, the man was taken to hospital.
186. The following extract from a statement by one of the paramedics concerned
explains his response to the emergency:
“At 0200hrs we received a call to HMP High Down. The time of the call is
approximate as we recorded the arrival time at the prison front gate as
0218hrs, and the call was received when we were at Epsom Ambulance
Station, so we had to drive to the location. On this occasion the
information stated, ‘male hanging obviously dead’. On arrival at the front
gate I wrote down the exact arrival on the patient clinical record. We
waited for the gate to open and passed into holding cell area of the gate
then through to the second gate into the court yard. The further gated
areas were opened for us until we reached the parking area. We were
then updated to say that CPR was being carried out, as we had queried
why we were going to a ‘deceased’. Just as we got the call the female
prison officer that had escorted us started to run. There were numerous
officers around. I started to run with the one female and a colleague
gathered more equipment. I arrived at the feet of the patient at 0225hrs.
There were several prison officers around the door of the room and at
least 2 to 3 people performing CPR on the male. We had a monitor so I
put him onto that and I started to ask questions in relation to the incident.
I had established no pulse and no respiration so CPR was continued.
Assistance was sought from prison staff. The particular rhythm show
meant that under our protocols we continued CPR and due to the time-
critical nature a collar was put on him and he was taken to the ambulance.
At 0245hrs we left in the ambulance from the place we had parked. We
arrived at the hospital at 0258hrs. The CPR and care was continued
throughout the journey and a prison guard was present and assisting
46
under my instruction. The patient was taken to the resuscitation room and
we were met by hospital staff. Our role was now over as hospital staff
were in charge of his care.”
187. The following table shows the timing of some of the significant events
recorded on CCTV that night, together with explanatory comments:
Time Event seen Comment
01.15.59 Officer approaches In response to his cell
The man’s cell door. Bell
01.16.29 Officer D joins the officer As above. Only Officer
at cell door. D has keys to
cell door.
01.16.46 Officer D lets the man The man is escorted to
out of cell. end of landing to stairs
leading to upper landing.
01.17.19 The man and above staff The man is let into Listener
appear on upper landing. suite, out of view of
He has arms folded. Slight camera.
bulge can be seen in left Bulge may conceal
sleeve of his jumper. the ligature he used.
02.10.15 First sight of staff movement This is in response to
near Listener suite. the discovery of the man
hanging.
02.10.52. OSG B appears on
landing looking towards
Listener suite.
02.10.55 The two officers and a third
male officer seen moving
towards Listener suite.
02.11.09 Same male
officer seen exiting from
Listener suite.
02.14.36 Black male officer seen This is an officer.
exiting Listener suite
looking distressed.
02.14.43 Same officer returns to
Listener suite
02.26.22 Officer seen carrying The equipment
emergency first aid is an ambu-bag and a
equipment across landing portable chair .
to Listener suite.
02.33.04 One male officer and one They are two officers.
female officer seen
crossing landing toward stairs
02.33.31 Same two officers seen They enter cell to
entering the cell. check for presence of
any evidence
indicating suicidal
intent.
02.34.13 Same two officers leave cell. They confirmed at
interview that they
realised they could
touch nothing in cell so
decided to leave.
02.34.50 Same two officers seen
crossing upper landing, empty
handed.
02.36.36 Male officer seen The document is the man’s
inspecting document on ACCT form. The officer is
47
upper landing. checking to see if there
are any comments about
risk. (NB The identity of this officer
has not been confirmed and so his
actions cannot be verified.)
02.29.30 The man is seen being
removed from Listener
suite on rescue chair.
02.49.49 CCTV footage ends.
188. The police later confirmed that no letter from the man explaining his intentions
was found in his cell or in the Listener suite.
189. My investigators interviewed the Samaritans coordinator for High Down
prison. They were keen to establish whether the man actually used the
telephone to call the Samaritans before he hanged himself and, if possible, to
discover whether he talked to them about killing himself. The co-ordinator
kindly volunteered to make enquiries of his colleagues. He later confirmed
that a call had been made to the Samaritans at approximately 1.17am and
that the call had lasted for approximately 53 minutes. It had been diverted to
the Brighton branch of the Samaritans. In keeping with the Samaritans’ policy
of confidentiality, neither the details of the contents of the conversation
between the prisoner and the member of the Samaritans who took the call nor
the identity of the caller could be disclosed. However, the co-ordinator gave
my investigators a strong indication that the caller was likely to have been the
man. The co-ordinator advised my investigators that, if an approach were to
be made to the Coroner requesting disclosure of the transcript of the
conversation between the man and the Samaritans, the Coroner might be
disposed to issue a court order instructing the Samaritans to disclose.
However, the Coroner has confirmed that this is not within his power.
Furthermore, the Samaritans later clarified that no transcript of the
conversation with them was made.
190. In the opinion of my investigators, taking into account the evidence presented
by those who were first to arrive at the Listener suite after the man had been
found hanging as well as that of the paramedic, he probably hanged himself
shortly before he was found.
Contacting senior staff
191. The following table shows the sequence of events recorded by staff in the
control room from the point when the man was discovered hanging:
Time Occurrence
02.10 Code red HB5 – H72 acknowledged
02.10 Ambulance called
02.18 Contact Duty Governor no response
02.18 Ambulance arrives
02.19 Duty Governor……………………….unclear
02.22 Ambulance centre phoned for update?
02.27 V2 gate locked open
02.28 Tried to contact Governor ????? no response
02.29 Tried to contact first Governor no response
02.30 Tried to contact second Governor no response
02.33 O1 requesting care team worker?
02.40 Tried to contact third Governor
48
02.41 Tried to contact fourth Governor
02.40 No response from any care team member / tried all numbers
02.43 Care team member reached – away from home.
02.45 O1 gives prisoner’s details of the man
02.46 Calling care team member closer to home – no response
02.48 Ambulance at gate leaving for hospital
02.50 Care team member contacted and put through to Oscar 1
02.50 Tried to contact fifth Governor – no response
02.50 Tried to contact sixth Governor– no response
02.55 Tried to contact seventh Governor – no response
02.55 Re-trying to contact eighth Governor – no response
02.55 Trying a care team member – no response
02.58 Trying ???? – no response
03.00 Made contact with Officer ??? – no longer ???
03.00 Contact made with ?????
03.05 Contacted ???
03.08 Trying ????
03.10 IMB contacted, will be arriving at prison before 04.00am
03.15 Contact
03.25 Officer from NOU called requesting details for above incident. All k
details passed on. Requires update before 07.00am. Call lasted ap
30mins.
03.40 Oscar 1 confirmed a Gov contacted and informed of incident.
03.50 Official arrived and escorted to HB5.
03.55 A Governor contacted again. Still no response.
04.07 The Governor finally contacted and put through to O1.
0400 IMB – in.
04.30 A Governor contacted.
04.45 Media relations called. 3 numbers tried and not getting through.
05.30 Police advised of bedwatch. CAD No: P308277587
06.20 Police arrive
192. The duty governor for that night had assumed that responsibility from the
previous duty governor.
193. The local contingency plans for the management of a fatal incident at High
Down require someone in the control room in the prison to inform the Duty
Governor as soon as possible by using a pager, a mobile telephone or the
home telephone number, details of which should be available to the control
room staff.
194. The control room log shown above confirms that a code red message was
received in the control room at 2.10am on 23 August. At 2.18am, an attempt
was made to contact the previous duty governor, who was shown on the daily
bulletin as being the duty governor. There was no response from him. The
investigation found that the control room staff were not aware that he and the
current duty governor had exchanged duties. As a consequence, the staff on
duty in the control room then went through the list of managers available and
telephoned them all. At 3.40am, the night orderly officer telephoned a senior
manager, who was not on call to the prison, to tell her that the man had been
found hanging and had been taken to hospital. This was the first time contact
was established with a senior manager.
195. At interview, the senior manager said:
“... We just sort of spoke through the process of who he [the night orderly
officer] should contact. They said they’d had difficulties with the duty
49
governor. I was aware that the contingency plans had recently been
updated with telephone numbers and asked were they looking in the right
section. Whether they were or not I can’t comment, but said you know
check again because the contingency plans have had the new numbers
put in.”
196. At his interview, the duty governor confirmed that he was called at about
4.00am. (The control room log shows that contact was made with him at
4.07am.) When asked by my investigators whether he thought this was the
first time anyone had tried to contact him, he said:
“It was, yes. I’d checked my pager. The lady that spoke to me said to me
we’ve been trying to call you, we’ve been trying to call every governor in
the establishment. We haven’t been able to, so I asked her what phone
number she’d had for me and she read a number. I didn’t recognise it and
I said to her I’ve got my mobile here, I’ve got my home phone here, my
pager here, I said I haven’t had any calls and she said well I had a list, I’ve
now produced another list and that’s where I’ve got your number from
now.”
197. When asked whether he thought the member of staff concerned had used the
wrong number, he said, “Yes, as far as I am aware”. He was also asked
whether the two hour delay in contacting him could have had an impact on
the management of the emergency. He replied:
“I don’t believe in this case it did because the first thing I did was ask
certain questions. For example, was the ambulance called, was CPR
applied. I went through a series of questions and the answers I had to the
questions were favourable in terms of the immediate care. But as far as I
could ascertain immediate care seemed to have taken place appropriately,
the ambulance came quickly, he’d left the establishment to go to hospital
quickly.”
Informing the man’s family
198. The duty governor said he called the deputy Governor who, in the absence of
the Governor, was in charge of the prison. He briefed him on what had
happened. He then left for the prison, some 75 minutes’ drive away. He said
he arrived at about 5.45am.
199. The deputy Governor said at interview that he was contacted at 3.15am and
that he later drove to the prison, arriving at about 4.30am, about ten minutes
after the duty governor. However, these times are not consistent with those
offered by the duty governor or with the control room log which records that
he was contacted at 4.30am. My investigators found that the gate book – the
register of entries and exits through the man prison gate – for that night
shows that the gate was opened at 5.35am to let him into the prison. The
book also shows that the gate was opened at 5.50am to allow the duty
governor to enter. (No criticism of the deputy Governor is implied here. My
investigator believed that, at interview, he did not recall the timings correctly.)
200. Upon arrival, the duty governor checked the man’s core prison record for
details of his next of kin. He told my investigators he had no difficulty
50
ascertaining who that was. He said that at about 6.40am he called the man’s
father. At interview, he described what happened next:
“I believe I said to him there’s been an incident at the prison today or
during the night involving his son and I believe I said that his son was
found hanging in a room and that he’s now gone to hospital. I advised him
that I was intending to go into the hospital and I said that I would like to, I
offered to meet him and we agreed that I would meet him at the hospital.”
201. He told the man’s father that his son was in a critical condition and was in the
intensive care unit. When asked whether the man’s father said anything
about how he would get to the hospital or not wanting to drive because of his
distress, he said, “No, although I never offered to get him a taxi which is a fair
point”.
202. During the duty governor interview, my investigators summarised the
chronology of events. The interviewer reminded him that he had had a
conversation with the control room just after 4.00am, had arrived at the prison
at about 5.45am, and had contacted the man’s father at about 6.40am. The
investigators asked him if he could have done things more quickly in the
circumstances. He replied:
“I think not really. I initially wanted to check all the details as much as I
could because I was wary that they’d have questions and I had to speak to
the Orderly Officer, I wanted to speak to the hospital themselves. So I
think initially when we phoned the hospital there was slight difficulty
getting through to the ward itself. We couldn’t actually do that but then a
PC phoned. I’m sure he phoned the establishment and spoke to the
deputy Governor. So then I managed to get through to the hospital and I
spoke to the PC briefly, got some information from him as to how things
seemed at the time at the hospital. Then once I did that I raised the
contact details for the family and made the phone call.”
203. My investigators asked the duty governor about a comment made by the
man’s father during the course of the investigation. The man said he thought
the officers from High Down in attendance at the hospital were insensitive to
him in that they were allegedly “standing around as if to join up their story”. In
response, he said:
“There is no story to join really. I mean we were really there for support. I
was certainly, I was wary that it’s a personal time for the family. I felt
particularly as we knew that the man was alive for a certain period of time.
And I suppose I felt I should be there for when he was declared dead if
that were to happen. Certainly it seemed as though he would be declared
dead by the end of the night or certainly by some stage in the morning.
And I felt it would have been completely inappropriate for the family to be
given that news and to find that there was no-one there from the prison,
certainly no-one there with any sort of management, you know, no
managers there. I felt that was insensitive. So I suppose you know, in
terms of the staff who were there, there was the officer there, an officer
being relieved by another officer, and there was that officer, there was
myself and the family liaison officer.” (My investigators were later
informed that the named officer was in fact another officer.)
51
204. The duty governor confirmed that at 11.30am on 23 August, hospital staff
conducted brain activity tests on the man which showed he had no brain
activity. He said that the hospital staff considered that he was therefore dead.
According to him, they nevertheless indicated that they would conduct a
further test after an hour. If this also indicated no brain activity, it would be
confirmation that he had died. He said the further test was conducted as
planned and this too showed no brain activity. As a result, a consultant
declared the time of death as 11.30am (i.e the time at which the earlier test
had been conducted with the same result). The man’s father and mother
were present when this declaration was made.
Appointment of a Senior Officer as initial family liaison officer
205. A SO was initially appointed as the establishment’s family liaison officer
(FLO). She had received no training for this role and was aware that
unsuccessful attempts had been made to contact those prison staff who had
been trained. She offered to perform the duties of FLO as she was
experienced in the management of safer custody and because of the urgency
with which an FLO was needed.
206. The SO decided to go to the hospital in order to make initial contact with the
man’s family. At interview, she confirmed she arrived around lunchtime. She
said that when she arrived the duty governor and another officer, whose
name she did not know, were present. She said the man’s father was sitting
at his son’s bedside while other members of the family were in a separate
family room. She confirmed that at this time the man was on a life support
machine. She said she stayed at the hospital until about 2.30pm or 2.45pm.
At interview, she explained:
“...The man’s dad actually asked us to leave. He approached us after and
asked if we were there because we had to be or because we were there
for the family and we said well both really, you know we’ve done what we
have to do. But we’re here in case any questions need answering and he
said oh in that case I’d prefer it if you left, so we said ok fine. And at that
time we gave him telephone numbers and told him that someone would
contact him.”
207. The SO then returned to the prison and completed her family liaison log. At
interview she explained that she also attempted to discover which of the
trained FLOs were likely to become available to take over from her. She said
she was conscious of the fact that some of them were engaged with other
cases and that it was important not to overload them. She knew that an
officer had recently completed his FLO training and had not yet acted in the
role. However, the officer was not due to return to work until the following
Monday (25 August). On that day, a decision was made to appoint him as the
FLO for the family.
Appointment of an officer as the next family liaison officer
208. The officer told my investigators he was appointed as FLO by the Deputy
Head of Residence, but said he thought he was not appointed until Tuesday
26 August. He said his first task was to gather as much information as
52
possible regarding the man’s death. To this end, he went to the Governor’s
office where the man’s prison record had been stored and took notes from his
history sheet and other documents.
209. The officer confirmed that he made an initial attempt at contacting the man’s
family by telephone at about 2.00pm on the day he was appointed as FLO.
He said the man’s father was not in. However, according to the man’s father,
the officer left a message on his answerphone saying he would ring him back.
He also claimed that the officer did not leave a contact number.
210. The officer said he called the man’s father back at about 4.00pm, some two
hours later. (The log kept by the officer shows he made the call at 4.30pm.)
This time, he answered the telephone. The officer explained to my
investigators that the purpose of his call was to introduce himself as the new
FLO and to let the family know what the job entailed. He also wanted to
arrange to meet them. He said he apologised to the man’s father for not
getting back to him sooner and explained that he had been trying to gather as
much information as possible. He said he then introduced the idea of
arranging a face to face meeting with him. (The officer’s log includes an entry
implying that the man’s father asked for a face to face meeting with him,
Officer B and the duty governor.) However, the conversation did not result in
any such arrangement being made as the man’s father became deeply
offended by some of the remarks allegedly made to him by the officer. He
called the prison and spoke to a SO, the first FLO, about his concerns. He
wanted to have a conversation with the duty governor but SO Price explained
that he was not in the establishment. The SO reported his concerns to the
Head of Residence who took it upon herself to ring him. Following their
conversation, she decided to terminate the officer’s appointment as FLO.
Another SO, who was one of the prison’s trained and experienced FLOs, was
appointed in the officer’s place.
Appointment of the SO as family liaison officer
211. On Wednesday 27 August, the SO telephoned the man’s parents to introduce
herself, offer them her condolences, and make an appointment to visit them
at their home the next day in the company of the first FLO.
212. They visited them on 28 August as promised. During their visit, the man’s
father repeated his concerns about the officer’s manner. The man’s parents
also asked a number of questions that neither member of staff felt able to
answer. However, when asked about the timings surrounding the discovery
of him hanging, the first FLO told them that their son had been placed in the
Listener suite at 2.00am on 23 August. This was later to prove incorrect. The
man’s father also expressed his concern at the delay in informing him and his
wife.
213. The new SO advised the parents that the Governor had offered to pay for the
costs of the funeral.
Letter of condolence
214. The Governor wrote a letter of condolence to the man’s parents in which their
son’s name was incorrectly spelt. As soon as this was noticed, the Governor
53
telephoned them to offer them his apologies. He followed this up with a fresh
letter.
Cremation
215. The man was cremated on 8 September. The FLO attended on behalf of the
Governor.
216. Two days later, the man’s parents visited his cell and the Listener suite under
arrangements made by the FLO. They also collected their son’s belongings.
The FLO maintained contact with them thereafter.
Prisoner support
217. The cases of all prisoners on ACCT forms on 23 August were reviewed that
day. The reviews comprised one-to-one interviews in each unit. The first
FLO arranged for the Samaritans to be available in the prison to any prisoner
who might want to see them.
Staff support
218. The deputy Governor chaired an initial debrief of the staff who were involved
in the emergency. Members of the prison’s care team were made available.
219. At the time of the investigation a full debrief had still not taken place. My
investigators were told that this was because no qualified debriefers were
available.
54
ISSUES
220. Here I examine:
• Whether the man’s physical and mental health needs were adequately
met while he was in custody.
• Whether his risk of self-harm or suicide was properly identified, monitored
and managed prior to the night of his death.
• Whether his risk was appropriately monitored during the night of his death.
• The design and use of the Listener suite.
• The standard of record keeping.
• Whether the response to the discovery of him hanging was prompt and
appropriate.
• Whether he was bullied by anyone at High Down and, if so, whether
appropriate measures were taken to deal with the bullies and maintain his
safety.
• Whether appropriate courtesies were afforded to the family after he was
discovered hanging and after his death at hospital.
Were the man’s physical and mental health needs adequately met while he
was in custody?
221. In this section, I rely heavily upon the findings of the clinical review conducted
by the clinical reviewers. In some instances, I also make judgements of my
own. I comment on the following issues:
− The man’s reception health screen on 9 June and his general health
assessment, or Wellman clinic, the next day.
− The management of his diagnosed condition of ADHD.
− The management of his substance misuse.
− The management of his self-harm and his risk of suicide.
Reception health screen and general health assessment
222. During his reception health screening interview at High Down on 9 June 2008,
the man was not considered to be at risk of self-harm or suicide. He told the
reception staff that, although he had a history of self-harm, he did not
currently feel suicidal. ACCT procedures were not initiated at that time.
However, the Prisoner Escort Record (PER) covering the journey between
Magistrates Court and the prison that day carried a notation that he was at
risk. The form was signed by the escort but not by anyone in the prison. The
investigation found no concrete evidence to show whether the PER was seen
by reception staff. Neither could the investigation show whether the
information in the Detained Person’s Medical Form completed at the police
station prior to his appearance in court was available to the bank nurse or any
other member of staff. As noted earlier, my investigator attempted to
55
interview the bank nurse on several occasions. However, each time an
appointment was made she failed to appear. I cannot be certain that, had the
comments on the PER and the Detained Person’s Medical Form been taken
into account, a different judgement about his risk would have been made.
Nevertheless, it is of self-evident concern that such information seems either
to have been unavailable or to have been ignored.
223. The following extracts from Prison Service Order (PSO) 1025 set out
guidance for the use of the PER:
Paragraph 1.4
“Whenever a prisoner is received from the custody of others, during or on
completion of a movement, the risk and vulnerabilities identified by the
previous custodian should be noted and acted upon, to protect the
prisoner and other prisoners, staff and the public.”
Paragraph 3.1
“When taking receipt of a prisoner, reception staff must request the PER
from the escort. Reception staff must sign the white top form at section 7
for receipt of the prisoner.”
Paragraph 3.2
“Reception staff must alert appropriate staff in the prison to any risks
identified on the PER, e.g healthcare and security staff/duty
governor/orderly officer.”
Recommendation 1
The Governor, should, in keeping with the provisions of PSO 1025, ensure
systems are in place to guarantee that PERs are always seen and studied by
reception staff, and that comments in PERs as to risk are taken into account
by staff when judging how best to care for and support individual prisoners.
Managers should carry out regular compliance checks.
224. On pages 8 and 9 of her report, the clinical reviewer summarises the
reception screen and Wellman (general health assessment) as follows:
“The first reception screening suggests a current charge of possession of
an offensive weapon. Again, the man denied being registered with a GP
currently, but did disclose he had been seen in High Down earlier in 2008.
He stated that he was not in receipt of any prescribed medication, had no
physical difficulties apart from asthma, but under substance misuse he
stated he was drinking cider up to five 3 litre bottles daily. He also stated
he had been taking DF118 medication and that he drank cider from
waking. In addition, he stated that he had been using heroin on a daily
basis, up to £250 pounds worth daily. Also, he suggested he had been
using crack cocaine. He suggested he had never had treatment from a
psychiatrist outside prison but described himself as a paranoid
schizophrenic. He stated that he was diagnosed but not treated for this
illness and, when asked to disclose self-harm, said that in January 2008
56
he felt depressed and cut his arm. However, he was not experiencing any
suicidal thoughts at that time (at the time of the health screen). Under the
planned action, he was referred to the Substance Misuse Services by the
bank nurse. In the subsequent Wellman health assessment that occurred
on 10 June, he has recorded his concerns about sexual health and his
requests for HIV or Hepatitis screening. When asked about medication
prior to coming into prison, he stated that he had been taking Ritalin,
antidepressants and epilepsy medication and gave the name of his
General Practitioner. He requested a special diet avoiding anything with
lemon or marmite. He was referred to the Medical Officer, the Hepatitis
clinic and for blood tests by the HCA who completed that assessment.”
225. The investigation found that, although the man had been in High Down on two
earlier occasions, his medical notes relating to those periods of imprisonment
were not available to reception or healthcare staff on 9 June 2008. On pages
42 and 43 of her report, the clinical reviewer comments as follows:
“The man has had three admissions to HMP High Down over a relatively
short period. It would be helpful for there to be a mechanism whereby
Prison Health Services could obtain past medical records which may
contain valuable background information to assist an individual’s care.”
The clinical reviewer recommends that there should be one unified health
record within the prison and that this should contain information from health
and substance misuse teams. She also says that the same record should
continue during a period of custody and should be available during
subsequent periods of custody. I endorse her recommendation and I repeat it
immediately below paragraph 247 below, along with other recommendations I
make.
226. At the consultation stage, the man’s parents expressed their concern about
the fact that when the First Night Officer saw him on 9 June, he did not open
an ACCT plan or refer him for a mental health review. I understand their
concerns, especially in view of his disclosure that he had self harmed “every
day for three years”. I nevertheless believe the officer’s decision not to open
an ACCT plan was reasonable given his presentation and demeanour. I have
decided not to make a formal recommendation on this matter, although with
hindsight I suggest that the officer ought to have considered the option of
referring him for a mental health assessment.
The management of the man’s diagnosed condition of ADHD
227. The man’s parents were especially concerned to learn whether medical and
other staff at High Down were aware that he was suffering from ADHD. They
also asked my investigators whether their son displayed any symptoms of
ADHD in prison and whether any members of staff knew how to deal with
those symptoms.
228. During the reception procedures on 9 June 2008, the man disclosed that he
suffered from ADHD and a range of other conditions. However, when he was
seen by the doctor the next day, he did not mention to her that he suffered
from ADHD. (At this time, it would appear that neither his previous prison
clinical records, nor his GP notes, nor the Detained Person’s Medical Forms,
57
were apparently available to the doctor.) In interview, the doctor could not
remember whether he displayed any signs of ADHD when she saw him.
However, she said if he had been displaying such signs she would have
discussed them with him and with the mental health in-reach team. When
asked whether a detox programme might have had an effect upon him if he
was suffering from ADHD, she said she thought it might.
229. However, the man did disclose that he had ADHD when he was interviewed
by the Healthcare Assistant for his Wellman assessment. When asked by my
investigators what could be done to help and support prisoners with ADHD,
she suggested that, aside from making others aware, she would normally
expect healthcare staff to take follow-up action.
230. The discipline staff to whom the man disclosed that he had ADHD told my
investigators at interview that, although they had heard of the condition, they
felt unqualified to pass an opinion as to whether some aspects of his
behaviour were symptomatic of ADHD.
231. In her clinical review, the reviewer confirms that the man was diagnosed with
ADHD in August 2005 when he was 16 years old. He was initially prescribed
Atomoxadine (a non-stimulant medication) which he took from April to
October 2005. The prescription was then changed to Concerta, a slow
release form of Methylphenidate, a commonly prescribed psycho-stimulant
also known as Ritalin. He continued to take Ritalin until May 2006 when he
reported the onset of seizures. A letter was therefore sent from the
Adolescent Community Mental Health Team to the hospital asking for him to
be assessed. Because of the likelihood that Methylphenidate could lower the
seizure threshold, he was advised to discontinue the medication at that point.
His case was closed by the Adolescent Mental Health Service in July 2006
after he had failed to keep his appointment and to attend group meetings.
The clinical reviewer comments on page 40 of her report that, as far as it was
possible to ascertain from the medical record, there was no suggestion that
he had ongoing treatment with stimulant medication for ADHD following the
discontinuation in 2006.
232. The clinical reviewer writes as follows on page 43 of her report:
“Had contact been made with the man’s General Practitioner, it would
have been possible to confirm that he indeed received a diagnosis of
Attention Deficit Hyperactivity Disorder in his mid teens. It would have
been clear that he had not taken medication for ADHD within the last [i.e.
the previous] two years. His other self-disclosure of suffering from
Paranoid Schizophrenia, Manic Depressive illness and Autism would also
have been excluded. Had he been referred to Prison Mental Health In-
reach Services, it is likely that these enquiries would have been made of
his General Practitioner and his diagnosis would have been clearer to
those managing him within the custodial setting. Unfortunately, the
opportunity to arrange this assessment at Reception did not occur
because of his non-disclosure of relevant information.”
233. On page 44 of her report, she concludes as follows:
58
“In terms of the management of the man’s Attention Deficit Hyperactivity
Disorder, the natural course of ADHD shows a gradual reduction in
symptoms with maturity and, although some individuals do go on to
continue to suffer with symptoms of ADHD into adulthood, these are the
minority. Most individuals with ADHD show a gradual resolution with
approaching adulthood and those on medication will often be encouraged
to discontinue medication for a number of weeks and months in order to
see if the original symptoms have now attenuated. It would appear from
the descriptions of him during his time in custody at HMP High Down that
symptoms of physical over activity were not present. There remained
some symptoms of Attention Deficit with poor concentration, distractibility
and disorganisation, but these were not so severe that they caused those
caring for him to consider asking for medical intervention.”
234. As a lay person, it seems to me that a possible cause of the untruthful claims
the man made about his family history may have been his propensity to seek
attention (a symptom of ADHD). His family made a specific request for my
investigators to ascertain the extent to which healthcare and discipline staff
were aware of the symptoms of ADHD. The clinical review addresses this
issue as far as the healthcare staff are concerned. I imply no criticism of any
member of the discipline staff who said they did not have any knowledge of
the condition. In any event, Officer B did ask for medical intervention by
referring him to the mental health In-reach team, given his concern at his
behaviour (whatever its cause).
235. He was again referred to the mental health in-reach team on 21 August by the
panel who conducted the initial ACCT case review the day after an ACCT
form was opened for him. However, no appointment could materialise from
the referral as he died two days later.
236. At the consultation stage, the man’s parents expressed their dissatisfaction
that healthcare staff did not act upon the information he provided during his
well man assessment. They cited the fact that during this assessment, he
gave details of his GP and confirmed that he had previously been taking
Ritalin, anti-depressants and epilepsy medication. They were also concerned
that the CARATs team did not act on information in the Drug Intervention
Record completed on 7 June 2008 while he was in police custody which
recorded that he suffered from ADHD. In light of their comments, I have
agreed to make the following additional recommendation:
Recommendation 2
Healthcare and CARATs staff must take appropriate action in response to
information received relating to prisoners’ healthcare needs or ongoing health
conditions. In addition, whenever a prisoner discloses details of medication they
were receiving in the community or the name of their GP, such information must be
communicated to healthcare staff who must take steps to verify that information as
soon as possible. Such steps are necessary to ensure that provided with continuity
of care.
237. The man’s parents also pointed out that he confirmed his diagnosis of ADHD
during the Wellman and CARATs assessments at High Down and during his
59
time in police custody. They were therefore concerned that this information
was not followed up.
The management of the man’s substance misuse
238. The investigation found that, as the man was an existing client of the
CARATs service in the community (he had most recently been assessed
by a community based CARATs worker on 7 June 2008 when he was in
police custody), he was automatically seen by a member of the CARATs
team at High Down shortly after his arrival there in June 2008.
239. In her clinical review, the second clinical reviewer offers the following views
about the man:
“It has been requested that I study the available documentation and
provide an opinion particularly on the impact of the man’s addiction and
the treatment of his addiction.
“There is no record of drug or alcohol misuse in his general practice
records, although his diagnosis of ADHD is fully documented. There is no
corroborative evidence from any other source available to me of previous
drug and alcohol misuse. However, on reception into custody he is
recorded as stating that he had been drinking 25 units of alcohol daily for
the previous 3 years and was using crack cocaine and cocaine powder to
a daily cost of £2200. It is unlikely that his account of his alcohol
consumption was accurate as he did not require an alcohol detoxification
on entering custody and likely this stated level of consumption of heroin
and cocaine was similarly exaggerated. There is no evidence of previous
treatment of addiction prior to entering prison. It would be of interest to
know if he had any previous period in custody and, if so, whether he
required treatment for withdrawal from alcohol or opiates.
“He was treated with substitute opioid, Buprenorphine, at levels that are
consistent with current national guidelines, to attenuate opiate withdrawal,
as [this] was the withdrawal regime for opiate detoxification. As is
documented, he initially requested and received a reducing detoxification
regime, changed his mind and requested a maintenance dose which was
prescribed, then again requested detoxification, his last dose being 16
August. He is recorded as being happy to be drug free and having
completed his detoxification. However, there is no record of urinalysis
results to confirm that he was abstinent from illicit drugs and a reference in
the transcripts of selling a stereo to pay for ‘puff’ (sic). In a community
setting, urinalysis would have been performed to monitor compliance with
prescribed medication and abstinence from illicit substances.
Buprenorphine is taken by the sublingual route, that meaning that the
tablet is placed beneath the tongue and is retained there until it dissolves.
If swallowed it is inactive. It may take up to three minutes for the tablet to
dissolve and the mouth should be inspected to ensure that it has been
fully dissolved. The difficulties in supervision on the [house] block and the
risk of diversion to another person are both noted in the documentation.”
240. My investigators were able to view the clinical records presented to them by
the local PCT, which contain copies of the first reception health screens and
60
Wellman assessments for the man’s two previous periods of custody at High
Down. In neither record is there any evidence that he was treated for opiate
or alcohol dependency at that time.
241. In her concluding remarks on page 49 of her report, the clinical reviewer
comments as follows:
“In summary, I am clear that the man was opiate dependent but not
alcohol dependent on reception into custody, [and] that the treatment he
received for his opiate dependence was in line with national guidelines
and was responsive to his requests for detoxification or maintenance.
However, I am not clear whether he was using illicit substances as there
are no recorded urinalysis results. This is not in line with national
recommendations or guidelines. It is regrettable that action was not taken
at his failure to attend CARAT treatment groups.
“However, withdrawal from opiates with a managed detoxification does not
precipitate depressive disorder or suicidal ideation and there is no record
of protracted withdrawal symptoms in him, such as severe insomnia, to
support the hypothesis that his ADHD was so exacerbated.”
Conclusions
242. On page 41 of her report, the clinical reviewer sets out her concluding
remarks as follows:
“The man was seen by the General Practitioner on his admission to HMP
High Down on 9 June and she found no evidence of him suffering from
any current mental disorders, although se was aware of his disclosure of
suffering from Schizophrenia in the past. Throughout his time in custody
there were no specific concerns raised about his mental health until
shortly before his death. There was mention at the end of July 2008 of
him awaiting a mental health assessment, but during interviews with staff
this appears to have been something he suggested was going to happen
as part of the court proceedings. He was in fact referred to the Prison
Mental Health In-reach Team following an episode of self-harm and
concerns about his disclosures of bereavement very shortly before his
death.
“At the time of his death, he was on an open ACCT document, and it
would appear from interviews with staff that he had been in the habit of
using both the Listener service and the Samaritans to support himself at
night whilst in custody. His death occurred in the Listeners Room after he
had been talking to the Samaritans.
“His substance misuse was managed with Subutex. He appears to have
discontinued the use of Subutex in July and, at the time of his death, he
was no longer on detoxification or maintenance medication. He did not
require treatment for alcohol detoxification and it may well be that he over-
estimated both his consumption of alcohol and illicit substances when
disclosing his pattern of usage to staff.
61
“There was no evidence in the record that he, at the time of his death, was
suffering from a depressive illness, nor any evidence of any other major
disorder. Staff in their interviews have described him at times as being a
quiet young man who gave limited responses to questions, but other times
he is described as having poor concentration, a degree of disorganisation
and perhaps some impulsivity. There did not appear to be physical over
activity or significant sleep difficulties noted by staff.”
243. It is recognised that the man gave staff inconsistent and confusing information
about his medical and psychiatric history in the early days of his sentence, but
it should have been possible for his disclosures to be verified by reference to
previous records. This systemic failure is too often revealed in the course of
my investigations. I urge the National Offender Management Service to act
upon the recommendations I and the clinical review team make in this regard.
244. The fact that the mental health in-reach team returned the man’s referral form
for correction, rather than acting upon, it is of concern. However, the service
manager for Surrey prisons who manages four prison mental health in-reach
teams, has placed this issue in context. I quote him as follows:
“At the time of the referral, there was a clear procedure about the
handling and management of referrals. In this instance, one of our
administration workers did not follow the process because ordinarily
we would telephone prison staff or email them if we needed more
information. The original referral should have been kept by in-reach.
“Despite this error, the man already had assessment booked for 27
August with our Consultant Psychiatrist. When a referral is received
for a patient who already has an assessment appointment booked, our
main concern would be to ascertain whether the new referral suggests
that more urgent action should be taken. Although our administration
worker should have informed the referrer that an appointment had
already been booked for him, there was nothing in the referral to
suggest immediate risks or concerns about self-harm.
“The mental health in-reach team respond to routine referrals by
offering an assessment where possible in 10 working days. From the
date the referral was received, he was already booked to be seen
within that timescale. Although it was not unusual for the mental health
in-reach team to telephone referrers to get more information, we have
to point out that this is often not practical. We accept that it would
have been alarming for the officer who referred to mental health in-
reach to find that the referral had been returned to him after his death.
At the least our usual response would normally have been to inform
the officer that an appointment had already been booked.”
245. In view of these comments, I make no formal recommendation about the
manner in which Officer B’s referral of the man was handled. However, I urge
the mental health in-reach team to do all they can to protect against a
repetition.
62
Was the man’s risk of self-harm or suicide properly identified, monitored and
managed prior to the night of 22/23 August?
246. During the reception procedures conducted upon his arrival at High Down on
9 June 2008, the man admitted to a history of self-harm but said he did not
currently feel suicidal. Thus, it was not considered necessary to initiate self-
harm monitoring procedures at that point. Reception staff in all local prisons
have little time to interview prisoners in depth or to make thorough
assessments of the risks they may pose. It is not unusual for reception staff
to conclude that a prisoner is not at risk of suicide if he tells them he is not
feeling suicidal, even when comments contained within a PER suggest
otherwise. I do not criticise the reception staff at High Down for not having
initiated self-harm monitoring procedures for him at that point. It seems to me
that their decision was reasonable in the circumstances. Although I make no
formal recommendation, I urge the Governor and the PCT to remind reception
and healthcare staff of the need to adhere to the provisions of Prison Service
Order 500 (Reception).
247. However, I am concerned that those who assessed the man when he arrived
at High Down seem not to have seen the PER which contained a notation that
he was at risk of self-harm or suicide. Neither did they have access to his
previous prison and medical records. As a result, they were unable to place
his disclosures in context. The officer who conducted the cell sharing risk
assessment for him during the reception procedures recorded that he was not
currently subject to ACCT procedures and that there was no evidence that an
ACCT form had been opened previously. The investigation found that during
his previous term of imprisonment, which had come to an end only a matter of
weeks earlier, he had in fact been subject to ACCT procedures.
248. Although there is no specific mention of any assessment of the man’s risk of
suicide in the record of the interview conducted by the doctor on 10 June, she
commented that she felt his mental state was appropriate with no sign of
psychosis. However, she too was disadvantaged by the fact that his previous
prison and medical records were not available to her.
249. As I have said earlier, had the man’s previous records been available during
the reception procedures, it does not mean that a different conclusion would
have been reached as to his current risk of self-harm or suicide. However,
the absence of – or the ignoring of – such important information represents a
significant failure (as I have commented at paragraphs 220 and 223 above).
Recommendation 3
The Governor should ensure that Reception staff are aware of the provisions
of PSO 2700, especially in relation to the use and handling of Prisoner Escort
Records (paragraphs 4.3 and 4.4 of that Order refer).
Recommendation 4
There should be one unified health record within the prison and this should
contain information from health and substance misuse teams. The same
record should continue during a period of custody and be available at
63
subsequent periods of custody. The National Offender Management Service
should ensure that this record, as well as the core prison record relating to
prisoners’ previous periods of imprisonment, is available at, or very close to,
the point of any subsequent admission to prison. When the unified health
record or core prison record is received after the initial healthcare screening
reports have been completed, the information in those reports should be
verified against the details contained in the health and prison records. Staff
should consider whether to take any action in response to any new
information contained therein. Healthcare staff should request a copy of any
medical records relating to the periods spent by prisoners in police custody,
as well as relevant GP records, and should ensure that all the significant
information is recorded in the prisoner’s unified health record.
Recommendation 5
The National Offender Management Service should ensure that judgements as
to risk of self-harm or suicide take into account historical information in
prisoners’ records.
250. Between his reception on 9 June and 19 August, the man reported two minor
injuries. The first was on 4 July when he pressed his cell bell to tell officers
that he had suffered a paper cut to his hand. At the same time, he produced
an improvised weapon – a toothbrush with a melted down head containing a
blade – claiming that he had fashioned it for his own protection. It was the
judgement of the officer who spoke to him on that occasion that the injury was
not the result of a deliberate act of self-harm. Rather, it was thought that he
had accidentally cut himself on the blade of the weapon he had handed in.
251. The second injury was on 19 August when the man scratched his wrist. The
nurse who examined him on that occasion concluded that the wound was so
minor that it required nothing more than soap and water to clean it. But the
same nurse recorded that he had also claimed to have taken 12 tablets of
Ibruprofen. The nurse took the precaution of taking advice from a Poisons
Unit. He was told that this number of tablets would be “well below toxic
levels” but that he might experience gastro intestinal disturbance. Prior to 20
August, this was the only occasion when he manifested self-harm risk
indications.
252. I am concerned that, following the incident on 19 August, no consideration
seems to have been given to opening an ACCT plan. Annex 8G of Prison
Service Order 2700 clearly states that an ACCT form must be opened
whenever a prisoner is found to have self-harmed. I am disappointed that this
was not done on this occasion. Although the impact was mitigated by the fact
that formal self-harm monitoring procedures were invoked the very next day,
staff should open an ACCT plan whenever a prisoner self-harms, no matter
how minor the resultant injury.
Recommendation 6
The Governor and PCT should ensure that all staff are aware of and follow the
provisions of Annex 8G of PSO 2700 which clearly states that an ACCT form
must be opened whenever a prisoner is found to have self-harmed.
64
Assessment, Care in Custody and Teamwork (ACCT procedures)
253. An ACCT form was opened on 20 August after the man told a member of staff
that he had suffered a series of bereavements in his family. It was also said
he had spoken to a Listener and felt very sad.
254. PSO 2700 sets out the procedures to be followed whenever an ACCT form is
opened. These include the timescales for each stage of the process. Those
stages are repeated here for convenience:
• complete a concern and keep safe form
• complete an immediate action plan
• carry out an ACCT assessment interview
• conduct a first ACCT case review
• draw up a care and management plan (a care map).
Concern and Keep Safe form and Immediate Action Plan
255. SO A completed a Concern and Keep Safe form at 1.45pm on 20 August.
Both she and Officer B then met with the man at 4.20pm to agree an
immediate action plan. The plan should be drawn up within one hour of the
risk being identified. The completion of his plan thus fell outside the
prescribed timescale by two and a half hours. At first glance, this may seem
to be an acceptable delay – understandable in any busy operational
environment. However, this is the very period in which an at-risk prisoner
may be at his or her most vulnerable. Whilst I make no formal
recommendation on this point, I cannot overstate the importance I attach to
meeting the provisions of PSO 2700 especially in respect of the timescales
set out in Annex 8G. Whilst I recognise the demands placed upon prison staff
in discharging their routine responsibilities, any tendency to let ACCT
standards slip is greatly to be regretted.
256. The SO decided that the man’s risk was such that staff should engage him in
conversation three times during the day, and that he should be observed
three times during the night. This requirement was recorded in the immediate
action plan itself as well as on the front cover of the ACCT form for all staff to
see. My investigators checked the extent to which this requirement was met.
The entries in the ACCT ongoing record equalled the required nature of
contact with, and observations of him, as well as the required frequency,
between the opening of the ACCT and 4.00pm on 22 August. The level of his
supervision during the night of 22/23 August is examined below.
ACCT case review
257. The first (and only) ACCT case review took place at 6.05pm on 21 August,
the day after the form was opened. SO A chaired the review in the company
of a unit officer and the man himself. The panel judged his risk of self-harm
or suicide as low, but recorded that he should be the subject of a routine
referral to the mental health in-reach team.
258. My investigators noticed that the two members of staff who attended the case
review were both from house block 5. No other disciplines were represented.
At the time of the review it was known that he had been upset and that he had
65
been in touch with a Listener on more than one occasion. It was also known
that his claims of bereavement within his family had been tested by Officer B
and found to be untrue. It was known that the officer had referred him to the
mental health in-reach team. Finally, it was known that he had been the
subject of a detoxification programme and that, on 16 August, he had asked
for his medication to be changed. I am therefore surprised that no member of
the healthcare team was invited to the case review. Another member of staff
who could have been invited was the chaplain. Annex G of PSO 2700 gives
the following guidance about the conduct of ACCT case reviews:
“The Unit Manager must chair the first Case Review and appoint a Case
Manager (it may be the same person) (minimum grade of Senior Officer or
Band 5 Nurse). Where the at-risk prisoner has severe mental health
problems, the case manager can still be from the unit on which they are
located. However in this event, the mental health professional must be
invited to case reviews (and given as much notification as possible of the
review time) and the Case Manager must seek their advice about how the
individual is managed.
“When considering who to invite to the case review, the Unit or Case
Manager ought not to be restricted by thinking only of staff who have met
the prisoner; they should try to think of who else could positively
contribute. It should also be attended by a member of staff who knows the
prisoner well (such as personal officer or the officer who raised the initial
concern). Where it is clear that there are mental health or drug/alcohol
issues, an appropriate member of healthcare staff must be invited to make
a contribution to the first review, in writing or by telephone if they are
unable to attend at such short notice. The appropriate member of the
Chaplaincy Team must also be invited to attend. Each case must be
treated individually and attended by staff involved in the care of the
prisoner, and where a provider of any specialist service (e.g. healthcare,
mental health services, substance misuse, Probation, psychology, family
advice, bereavement counselling) is referred to or otherwise involved in
the care of a prisoner on an ACCT Plan, that specialist must be invited to
contribute to the ACCT case reviews of that prisoner.”
Recommendation 7
The Governor should ensure that ACCT case reviews are conducted by multi-
disciplinary panels in keeping with the provisions of Annex 8G of PSO 2700.
(I emphasise here that a similar recommendation was made by Her Majesty’s
Chief Inspector of Prisons in the report of her inspection of High Down,
published in August 2006. She said that case reviews should be attended by
representatives of all departments that have regular dealings with the
prisoner. This recommendation was repeated at paragraph 2.59 in the report
of the HMCIP inspection that took place in May 2009.)
259. Whilst I acknowledge Officer B’s presence of mind in calling the man’s
parents on 20 August in order to verify the claims of bereavement he had
made, I am concerned that neither he nor anyone else in the prison thought of
consulting him as to whether he might give his consent for staff to inform his
66
parents that he had self-harmed and that the ACCT monitoring procedures
had been initiated that day.
260. Paragraph 13.3.3 in Chapter 13 of PSO 2700 sets out the following guidance
for contacting the family after a prisoner has self-harmed:
“After consultation with the prisoner, the nominated next of kin must be
notified unless:
• there is a clinical reason not to, or
• if aged 18 or over, the prisoner does not consent (when asked, the
prisoner’s response must be noted in the ACCT plan …)
• the prisoner’s Care Map indicates otherwise.”
Recommendation 8
The Governor should remind his staff that, whenever a prisoner self-harms,
the next of kin should be informed in keeping with the provisions of Chapter
13 of PSO 2700. The Governor should also remind his staff of the importance
of ensuring that key information provided by the next of kin, especially that
which may relate to a prisoner’s physical or mental health, should be recorded
in the prisoner’s ACCT record (if there is one) and shared with healthcare staff
as soon as possible.
Care map
261. The ACCT case review panel drew up a care map with the man’s agreement.
A target was set for each of the three issues that were considered to be
important for him to resolve: his back pain, his need to be employed and his
tendency to cut himself when upset. However, the care map contains no
reference to the earlier referral of him to the mental health in-reach team or to
the support by CARATs that was considered necessary in the immediate
action plan.
Further ACCT case reviews
262. The next ACCT case review was scheduled for 28 August. In the event,
neither the appointment with the in-reach team nor the ACCT case review
could take place. The ACCT form was still open when he died.
Was the man’s risk of self-harm or suicide appropriately monitored during the
night of his death?
263. Two OSGs were the only members of staff on duty in house block 5 during
the night of the incident. Whilst OSG A was a relatively experienced member
of staff, having worked exclusively as a night patrol for the previous eight
months, OSG B was deployed as a night patrol for the first time at the
beginning of that week.
264. At interview, OSG A told my investigators his shift began at 8.00pm. He said
it was usual for there to be a discussion between the staff on the evening shift
and the night staff about events of the day. He said the handover also
included a check of the Staff Observation Book. He said he saw the Staff
67
Observation Book when he started his shift but there were no entries in it
relating to the man. He initially seemed unsure during interview as to whether
he knew at the beginning of his shift that he was subject to ACCT procedures.
However, he soon recognised that he had made entries in the ACCT form.
He also admitted that his normal routine was to go through any open ACCT
forms and ascertain the frequency of observations for each prisoner. He
recalled that the man was the only prisoner in house block 5 subject to ACCT
procedures that night.
265. The front cover of the man’s ACCT form clearly shows the requirement for
him to be checked three times during each night. As I have reported at paras
141-155 above, the investigation found that OSG A had made three entries in
the ACCT ongoing record during the night. It may be helpful to repeat those
entries here:
8.30pm – “Checked, okay. No issues raised.” (the OSG confirmed at
interview that, before making this entry, he had spoken to the man through
the observation panel in his cell door and that he thought he seemed
perfectly alright.
Midnight – “Checked, ok. He pressed ECB [Emergency Call Bell].
Requesting Listeners.” (The OSG told my investigators that, on this
occasion, he spoke to him through the observation panel and that he
simply said, ‘Gov, can I have a Listener?’)
2.00am – “Samaritans phone requested.” (During the course of the
investigation, the OSG agreed with my investigators that the time of this
entry was incorrect. The investigation proved that the man asked to speak
to the Samaritans at approximately 1.17am and not at 2.00am.)
(At interview, the OSG told my investigators he intended to check him again
at either 3.00am or at the termination of his telephone conversation with the
Samaritans.)
266. As the OSG was not authorised to let the man out of his cell, he passed the
request on to Officer D, the assistant night orderly officer. The officer told my
investigators that, in ordinary circumstances, prisoners who asked to speak to
the Samaritans would do so from their cell, using a portable telephone
handed to them by staff. However, the signal on one side of the building was
so poor that there was little or no reception. As a result, the practice was to
allow any prisoner in that area of the building to call the Samaritans from the
Listener suite where the signal was reliable. He also said that some prisoners
had been abusing the system by using the Samaritans phone in their cells to
charge up their own mobile phone batteries or to call relatives or friends
rather than the Samaritans. He explained that the use of the Listener suite
reduced the level of abuse, “as prisoners knew they would be monitored more
closely there”. (I need hardly add that the man was not in fact monitored at all
during the 53 minutes he spent in the suite prior to being found hanging.)
267. The officer allowed the man to leave his cell and, in the company of another
officer, escorted him to the Listener suite on the landing above.
68
268. Officer D admitted that he did not give the man a rub down search before
allowing him out of his cell for fear that he would become angry if he was
searched. The very act of letting a prisoner out of his cell at night, when
staffing levels are at their minimum, could represent a threat to security and
control. However, the Governor has pointed out that night staff are
sometimes faced with operational circumstances that render rub down
searching inappropriate. He takes the view that the officer’s judgement not to
search him was justified because, in the circumstances, it was more important
both to his wellbeing and to the safety of the prison to avoid confrontation
than to carry out a rub down search.
269. The investigation found that the man must already have manufactured the
ligature with which he later hanged himself and carried it hidden to the
Listener suite. A rub down search might possibly have led to discovery of the
ligature. (When his parents viewed the CCTV footage, they noticed a bulge in
the left sleeve of his pullover and came to the conclusion that this was
probably where he concealed the ligature. Although no firm conclusions
could be drawn in this regard, my investigators agreed that it was possible.)
270. At the consultation stage, the man’s parents expressed their view that my
report should highlight the fact that, in failing to search him before he left his
cell, the officer did not comply with the local searching policy. His parents
take the view that this was of extreme importance “in light of the probability
that he had fashioned a ligature from a sheet in his cell and concealed this in
the left sleeve of his pullover visible on the CCTV footage”. They added that,
had the officer searched him, it was likely that he would have discovered the
ligature.
271. However, I believe that anything other than a strip search could not be
guaranteed to reveal the presence of a ligature which a prisoner had hidden
on their person. I agree with the views of the Governor that the officer’s
decision not to search the man was justified in these circumstances.
However, I hope that the following recommendation will provide an
appropriate safeguard against complacency.
Recommendation 9
The Governor should remind his staff of the need to rub down search any
prisoner allowed to leave his cell at night unless, in the particular
circumstances they face, it would be inappropriate to do so.
272. The CCTV footage showed that there was very little, if any, interaction
between the two members of staff and the man during the brief journey to the
suite. There was no evidence that either both officers asked him whether he
was alright or offered him support beyond being allowed to speak to the
Samaritans. His request to speak to a Listener and his subsequent request to
speak to the Samaritans ought to have suggested the possibility that his risk
of self-harm or suicide had increased. That suggestion is in keeping with the
spirit, if not the letter, of the comments the Governor makes on page 31 of the
local suicide prevention procedural document about the need for staff to be
alert to the possible heightened risk to a prisoner when he asks to use the
Samaritans phone.
69
Recommendation 10
The Governor should remind his staff of the importance of adhering to the
provisions of paragraph 31 of his local suicide prevention strategy which
requires them to be alert to the possible heightened risk to a prisoner when he
asks to use the Samaritan’s telephone.
273. In relation to this recommendation, the man’s parents commented at the
consultation stage that staff should attempt to speak to the prisoner and
discuss his or her concerns to establish their state of mind and to enable an
assessment of the prisoner’s risk. They suggest that details of their
conversations should be recorded in the ACCT plan. They said that staff
should also consider the need to increase the frequency of observations of at-
risk prisoners following any telephone conversations with a Samaritan.
274. Once the man had been locked in the Listener suite, he was left alone for
approximately 53 minutes before he was found hanging. At the time, no clear
general instructions were in place at High Down for the observation of
prisoners during periods when they were locked in a Listener suite. Of
course, in normal circumstances prisoners would not find themselves alone
as the prime function of the suite is to enable a prisoner and a Listener to be
in the room together. The Governor has made the comparison that had he
been able to use the Samaritans telephone in his cell, there would have been
no expectation that he would be supervised. Whist I have some sympathy
with that view, I wonder whether, had the provisions of paragraph 31 of the
local suicide prevention strategy been applied, a decision might have been
taken by the night staff to increase the level of observations of him had he
remained in his cell.
275. The requisite number of checks to be carried out in respect of the man by
night was three. By the time he reached the Listener suite, two of those
checks had, according to OSG A, already been carried out. As has been
pointed out above, the OSG said he intended to carry out another check
either at 3.00am or when his conversation with the Samaritans came to an
end. Thus there was no definite plan to observe him before 3.00am. My view
is that, if the practice of allowing prisoners to use the Listener suite to
telephone the Samaritans is to continue at High Down, they should be more
closely monitored. It might be better if the practice is brought to an end.
276. I understand that, since the man’s death, the Governor has introduced a
system whereby a member of staff is stationed outside the Listener suite
purely to observe any prisoner left alone in the suite to telephone the
Samaritans. I support this decision.
ACCT observations and pegging
277. During one of the interviews conducted with OSG A, he told my investigators
he carried out his pegging rounds “on the hour, every hour”. He also said he
preferred to carry out his ACCT checks while he did his pegging rounds. He
was asked whether he carried out any pegging in house block 5 between
1.17am and 2.10am on the night of 23 August 2008. As I have reported in
paragraph 163, he replied as follows:
70
“No. Pegging starts from approximately 1.00am and lasts for
approximately 15 minutes. During this time, I have to peg throughout the
entire unit. This policy is written down in local orders. We are given a
copy of these when we start our shift. I pegged from approximately
1.00am that night to approximately 1.15am. I did the whole house block.
This included the landing on which the man was located as well as the
landing on which the Listener suite is located. After I had finished, I
answered a cell call alarm from him at about 1.17 am.”
278. The CCTV footage made available to my investigators shows no picture of
the OSG patrolling house block 5 at the times mentioned above. This is a
matter of great concern to me.
279. My investigators examined Local Operating Procedure (LOP) 03/2006 – Night
Procedures. The following are extracts from that document:
“The night pegging system will be operational between 22.00 hours and
06.00 hours. The first walk must commence by 22.00 hours. Each
subsequent walk must commence within 30 minutes of the completion of
the previous walk.”
“The patrolling Officer may miss two pegging walks for the purpose of
taking meal breaks. Pegging will recommence 45 minutes after the
previous pegging walk.”
280. The wording of the LOP makes no provision for pegging to be carried out “on
the hour, every hour” as suggested by the OSG. If it was his practice to patrol
in such a manner, he was in breach of local orders.
Recommendation 11
The Governor should ensure that the full provisions of his Local Operating
Procedure for night procedures are both known and complied with by all those
staff who are likely to be on duty in the prison by night. Special emphasis
should be placed on pegging procedures.
Recommendation 12
The Governor should remind his staff of the importance of ensuring that
checks of prisoners – especially those considered to be at risk of self-harm or
suicide – are not carried out on a predictable basis.
Conclusions
281. Although credit should be given to SO A for opening an ACCT form on 20
August, the first and only case review held the next day was not conducted in
accordance with the provisions of PSO 2700 which clearly state that the
review panel should comprise a multi-disciplinary team, including a
representative of the healthcare department.
282. When the man asked to speak to a Listener and then to the Samaritans
during that particular night, no consideration was given to the heightened risk
71
of self harm or suicide he may have presented. This is contrary to the
provisions of paragraph 31 of the local suicide prevention strategy.
283. OSG A seemed to be in ignorance of the local orders for the conduct of
pegging and timing of pegging. Instead of following laid down procedures, he
carried out his checks in a predictable manner. (I am also critical of the OSG
in respect of the discrepancies between the timing of the entries he made in
the man’s ACCT ongoing record during the night and those shown on the
CCTV footage.)
The design and use of the Listener suite
284. On the day the investigation was formally opened, my investigators examined
the Listener suite where the man had been found hanging. They were told
that the suite was in fact a multi-functional room that was often used for staff
meetings and like purposes. Its size approximated to that of two cells joined
together. The entrance to the suite comprised a low security door with a
glass screen built into it and the adjacent wall. The room was L shaped, such
that it was possible for someone left alone to be partially out of the sight of an
observer outside. The room looked untidy. Inside were a table and some
chairs, a bedcover, and a vacuum cleaner attached to a length of electric
cable. It would have been possible for a prisoner to fashion a ligature from
these materials, especially from the bedcover. There were numerous fittings
on the ceiling and walls that could easily be used as ligature points.
285. Although the room was described by staff and managers as a Listener suite,
that specific term is not used Prison Service Order 2700. At Annex 10c of
that PSO, references are made, inter alia, to Listener Support Suites and
Time Out Rooms.
286. According to the PSO, a Listener Support Suite provides joint accommodation
for a prisoner requiring peer support and a Listener. The accommodation
should normally comprise a double cell with separate areas for each prisoner
to occupy.
287. A Time Out Room is a cell or room for a prisoner requiring peer support to
meet with a Listener for a short period of time. The term Time Out Room best
describes the design and function of the room in which the man hanged
himself. The table below shows the guidance set out in Annex 10c of the PSO
for the design and usage of Time Out Rooms:
Physical requirement Single cell sized room. The room should
appear less institutional than normal wing
locations. The room should be furnished with
soft chairs with a low, coffee type,
table. The flooring should be vinyl. The
windows can be curtained and tea/
coffee making facilities should be
provided. The cell/room door should be
anti-barricade. Rooms should have a
cell-call system, preferably auditable.
Time out rooms are not to safer
specifications.
Certified Normal Time out rooms do not form part of the
Accommodation (CNA) CNA count.
Location Time out rooms can supplement or
72
replace support suites. They should be
provided in First Night Centres/
Induction Units. They can also be
provided on normal wing locations.
Staffing requirements Time out rooms operate with trained
Samaritans/Listeners. There should be
sufficient Listeners available to enable a
time rotational relief pattern. Listeners
will become fatigued where they have
provided peer support for prolonged
spells. Prison staff are required to bring
a prisoner in need of peer support and
the duty Listener to the time out room.
Profiling/protocols should reflect all
required transits to and in and out of the
time out room.
Usage A time out room provides an area that is
less institutional for the provision of peer
support. Listeners and those requiring
peer support will be brought together. If
prolonged support is required the duty
Listener will need to be rotated with other
Listeners.
A time out room is not to a safer
specification and therefore a prisoner
requiring peer support must not be left
unattended.
Prohibited usage A prisoner requiring peer support should
never be left alone in a time out room.
288. The room in house block 5 at High Down known as the Listener suite was not
furnished in keeping with the above provisions, although it seemed to be used
for the same purpose as a Time Out Room. The man was left alone in the
room for approximately 53 minutes. He was placed in the room, not to benefit
from peer support (i.e. to be with a Listener), but to enable him to speak
confidentially to the Samaritans. In normal circumstances, it would not have
been necessary for him to be placed in the room to speak to the Samaritans
as the dedicated telephone would have been passed to him for use in his cell.
289. My investigators visited the Listener suites in some of the other house blocks
at High Down. They were disappointed to find yet worse conditions in some
cases. In one suite they found builders’ rubble on the floor. However, the
suite in the segregation unit stood out as a good example of how such a
facility should be organised: it was furnished with soft chairs and did not look
like a cell or an office.
Conclusions
290. I do not criticise the decision to allow the man to telephone the Samaritans
from the Listener suite and I understand why he was left alone there.
However, I believe the fact that the suite had been attributed the status of a
multi-purpose room had the effect of eroding its role as a facility for the care
of at-risk prisoners. In my view, insufficient attention was paid to furnishing
the room for that purpose in keeping with the provisions described in PSO
2700 for Time Out Rooms. Moreover, the term Listener suite is unhelpful as it
does not tally with terminology used in the PSO.
Recommendation 13
73
In conjunction with Prison Service Headquarters, the Governor should
consider the merits of re-designating all Listener suites as Time Out Rooms.
At the consultation stage, the Prison Service rejected this recommendation.
The following response was received:
“The Governor can designate his cells in whatever way he wishes and does
not need the agreement of Safer Custody and Offender Policy Group or
Prison Service Headquarters.”
Recommendation 14
The Governor should ensure that clear instructions for monitoring prisoners
whilst they are in a Time Out Room are included in his local Suicide
Prevention Procedural policy. This is especially important where prisoners
subject to ACCT procedures are concerned.
At the consultation stage, the Prison Service rejected this recommendation.
Instead steps have been taken to ensure that the room is no longer used by
prisoners who are alone. The following response was received:
“High Down does not have Time Out rooms. The problem with the Samaritans
phone signal/reception has been rectified by the installation of boosters.
Prisoners do not now have to use a listening room to call the Samaritans.
The room is only used when Listeners are present.”
Also at the consultation stage, the family solicitors commented as
follows:
“The man’s parents are astonished that the PPO does not criticise the
decision to allow him to call the Samaritans unsupervised from a room which
was wholly unsuitable for this purpose and did not meet the Prison Service’s
own safety standards.”
The standard of record keeping
291. The investigation found several instances of poor record keeping, some more
significant than others. The following are examples.
292. Regular entries were not made in the man’s clinical record by substance
misuse nurses after they had seen him. The substance misuse lead nurse
told my investigators this was contrary to his expectations. It is important that
information about a prisoner’s acceptance or rejection of detoxification
medication is entered in his clinical record so that the complete picture of his
healthcare is made visible to all healthcare staff.
293. Following a minor act of self-harm on 4 July, when the man told an officer he
had been attacked by another prisoner red marks were visible on both sides
of his head. Although the officer who noticed these marks recorded the fact
in his prison record, she failed to complete a form F213 – the report of an
injury sustained by a prisoner. Had she done so, he would have been
74
examined by a nurse or a doctor and an assessment of his treatment needs
would have followed.
294. On another occasion, the same officer failed to raise the form after the ma
had reported that he had sustained what he described as a paper cut on his
hand. Staff should complete the F213 form whenever a prisoner sustains an
injury, however minor, not least because the record will reflect the frequency
and nature of any injuries sustained. Medical and discipline staff will thus be
better informed and able to decide what, if any, interventions are necessary in
the process of discharging their duty of care to prisoners.
295. Although there was no evidence that any of these examples of poor record
keeping related to the man’s death, I must draw attention to the need for staff
to follow the required procedures.
Recommendation 15
The Governor and the PCT should remind their staff of the importance of
completing a form F213 or, if necessary, a form F213SH, whenever a prisoner
sustains an injury, no matter how minor.
296. At the consultation stage, the man’s parents reinforced their concern that he
did not write his own initials on the Drug Intervention Record (DIR) completed
on 11 June 2008 (see paragraphs 64-66 above.) Through their solicitor, they
wrote:
“As is acknowledged the initials are neatly written in a form of
handwriting that seem different from that seen in his signature. It is
noted that the member of the substance misuse team denies he wrote
the initials. It is possible, however, that the initials were completed by
a third party and it is unclear whether any steps were taken to
investigate who else has access to the DIR and whether the initials
could have been written by someone else after completion of the form.”
297. My investigator had no reason to doubt either the member of the substance
misuse team or the CARATs worker’s explanation of this matter. Whilst I
understand the parents’ concerns, I am of the view that no further
examination of the issues they raise in this connection is warranted.
298. On 21 July and 11 August, the man appeared at Magistrates Court, either by
video link or in person. His record contains little, if any, detail of the outcome
of either hearing. The importance of recording in prisoners’ files details of
decisions made at their court hearings, as well as of their reactions to those
decisions, cannot be overstated. Prisoners often react badly to sentencing
decisions or to a refusal by the court to grant bail.
299. Perhaps the most significant example of poor record keeping was that relating
to the entry made by OSG A in the man’s ACCT ongoing record at 2.00am on
the night of the incident which proved to be grossly inaccurate (by 53
minutes). This was not just poor record keeping. It may fairly be described
as an act of incompetence on the part of the OSG. (My investigators, who
interviewed him three times so that he could account for the discrepancies,
75
concluded that, as serious as this error was, there was no evidence that he
had lied about it.)
300. At consultation stage, the man’s parents expressed their concerns that the
CARATs team did not record any attempts to engage him in his care plan or
to review his care plan. They were also concerned that his CARATs case
record simply includes an entry which records ‘client no longer ITDS
[Integrated Drug Treatment System]’ but gives no reason for this decision.
Recommendation 16
The PCT should instruct its substance misuse staff to make entries in
prisoners’ clinical files whenever they see prisoners, especially in relation to
detoxification issues and events.
Recommendation 17
The Governor should remind staff of the importance of ensuring that
contemporaneous, accurate and legible entries are made in prisoners’ core
files, especially in ACCT forms. Appropriate training should be available to
those staff who may require it.
Was the response to the discovery of the man hanging prompt and effective?
Opinion offered by Back to Life Ltd
301. A company known as Back to Life Ltd was asked by the local PCT to provide
responses to the following questions posed by my investigators:
• Was there an effective response from healthcare staff when the man was
found hanging?
• What equipment was used and what was the level of training of the staff
involved?
• Can the review comment on the fact that OSG B did not take part in the
emergency first aid as she had not been trained? Was it correct for her to
do nothing because of that?
Was there an effective response from healthcare staff when the man was
found hanging?
302. Back to Life Ltd submitted the responses shown below:
“Based on the information provided, it is the opinion of the reviewer that
there was an effective response by both healthcare workers and prison
officers when the man was found hanging. It is appropriate that if there
was doubt regarding a palpable pulse and the casualty was not showing
signs of consciousness or breathing for the staff to continue CPR.
“Without being present at the arrest, it is not feasible to determine how
effective the CPR was, but documentation supports the use of current
guidelines by staff - being 30 compressions to 2 ventilations, the use of
76
adjuncts such as a bag valve mask and oxygen and the placing of a
defibrillator/ECG onto him.”
What equipment was used and what was the level of training of the staff
involved?
303. The company responded as follows:
“Radios were used to provide an emergency code 1 (or code red)
message to other officers to gain swift assistance and alert the prison
control room of an incident. An emergency key kept in the pouch of the
officers was used to gain immediate access to the room. A ligature cutter
in the possession of OSG B was used to cut the ligature when the man
was lowered down. A bag valve mask with Oxygen 15 litres … was
administered to him on arrival of the red bag. A defibrillator or ECG was
placed on his chest and left in position.
“A saturation monitor was used and recorded a saturation reading of 69%
some time during the emergency procedure. [The company’s
spokesperson later explained that a saturation monitor is used before or
after a cardiac arrest. It is placed on a finger or ear lobe when the heart is
beating. It is used to monitor a person’s oxygen saturation level in their
blood. A normal reading of a healthy individual breathing room air would
vary between 95% and 100% but may sometimes be lower, depending
upon what they are doing. She said it is not usual for this equipment to be
used during a cardiac arrest as the blood supply to the finger or ear lobe is
usually insufficient to gain an accurate reading when the heart is not
beating. It was their belief that if this reading was taken during the cardiac
arrest, its accuracy was questionable and it should not have changed the
management or decisions of the cardiac arrest team in any way.]
“A blood pressure cuff was placed on the man and a recording of 45
systolic over 32 diastolic blood pressure was documented. [The
spokesperson later explained that a blood pressure reading is taken to
measure how strong the heart is beating and how well the blood is
circulating to the rest of the body. She said it is not usual for this
equipment to be used during a cardiac arrest as the blood supply to the
rest of the body is usually too poor to get an accurate and reliable reading
when the heart is not beating. It was her belief that if this reading was
taken during the cardiac arrest, its accuracy was also questionable and it
should not have changed the management or decisions of the cardiac
arrest team in any way.]
“A pulse rate of 115 was documented from the blood pressure machine
(sphygmomanometer). [The spokesperson later explained that blood
pressure machines may provide information about the pulse rate of a
person with a normal heart beat. She said that they are not a reliable
source of determining the strength of a person’s heart beat and they are
not a reliable source of recording information in a cardiac arrest. Her
opinion was that the only way to determine if a heart beat has returned,
and the rate of the heart beat, is to feel for a pulse with your fingers whilst
looking for signs of life, and counting the number of beats per minute
whilst looking at a clock. She said that in the absence of the Ambulance
77
AS11 – the ambulance documentation sheet – she was unclear whether
the heart beat had returned prior to the man’s departure from High Down
to hospital.)
“Staff Nurse B took other equipment to the cell which included a blood
glucose measuring machine.
“From the three interview transcripts provided to the reviewer, it appears
that the level of training for staff involved was the following:
OSG B – No resuscitation training
OSG A – Unclear
Staff Nurse B – Unclear. He suggests that he attended a basic life
support update or first aid training (which includes basic life support) in
2006 but later suggests he had done it in 2007. He states he is required
to have an update yearly.
“The use or availability for use of all the equipment stated in the list above
is appropriate in a peri-arrest (before or after a cardiac arrest when
spontaneous circulation has returned, i.e. there are signs of life) and
cardiac arrest scenario.
“Based on the information provided, but without reviewing the equipment
personally, the reviewer believes that the prison appeared appropriately
equipped to manage the emergency situation that arose from the man’s
hanging. It is not possible without an in-depth audit to determine whether
the type of equipment alluded to in this document was functioning
effectively or met all the current standards in resuscitation.”
304. In a subsidiary report submitted on 7 August 2009, the spokesperson
comments on the involvement of Nurse A. She offers the following
conclusions as to his actions:
“Based on the information provided, it appears that the nurse took an
active role in cardiac compressions and took over massage from the OSG
to give him a rest. He also helped co-ordinate activities to minimise any
delay of the arrival of the paramedics and provided referral paperwork to
go with the man to hospital.
“It is the opinion of the reviewer that the information contained within this
interview [i.e. that of Nurse A] suggests that the healthcare worker in this
case appears to have provided an effective response.”
305. As for the equipment used by Nurse A and as to his training, the
spokesperson comments as follows:
“With regards to Nurse A’s interview, he makes reference to the use
during the resuscitation of the man of:
• an ambu bag
• a defibrillator
78
“He also comments that additional equipment was brought to the room,
comprising:
• a blood pressure machine
• a BM machine (this measures blood glucose)
• a machine ‘that you place on the finger to record the oxygen’. (This is
more commonly known as a ‘saturation monitor’.)
“Level of training of Nurse A – he states that he is CPR, Manual Handling
and Health and Safety trained, although he does not say when.”
Conclusions
306. The spokesperson offers the following concluding comments:
“The equipment mentioned by Nurse A in his interview is all appropriate
for use in a peri-arrest and during a resuscitation attempt.
“Aspects of all the training courses undertaken by the nurse can help to
develop the skills to manage a resuscitation attempt. There is no
documentation to inform the reviewer how recently any of these training
course were undertaken.”
Can the review comment on the fact that OSG B did not take part in the
emergency first aid as she had not been trained? Was it correct for her to do
nothing because of that?
307. The spokesperson responded as follows:
“From the statements it appears that OSG B responded appropriately and
swiftly to a call for assistance. She then assisted OSG A by cutting the
ligature around the man’s neck and helping to lower him to the floor.
Although from the documentation it appears she had not received any
training in the cutting of a ligature and some comments suggest it may not
have been done according to correct procedure, it appears that she did
assist the other OSG in successfully lowering the man to the ground to the
best of her ability in order to enable resuscitation attempts to begin.
“If as stated within the interview Officer D arrived within 20-30 seconds of
the call, then it would suggest that only a few seconds passed once the
man was placed on the floor before he arrived.
“OSG B comments in her interview that once they had lowered the man to
the floor she heard the voices of other individuals responding to the
emergency and called to help guide them to the location. OSG A and the
officer then commenced resuscitation.
“It is unclear as to whether OSG B had been asked to get the first aid kit or
decided to do this of her own volition. Someone without training may well
believe that this would provide some equipment to help the situation. If
she collected a basic first aid kit it should have contained a face shield or
mask to provide staff with some protective barrier when performing mouth
to mouth resuscitation. If she had mistakenly called it a first aid kit when it
79
was indeed the red resuscitation bag then this would have contained
important equipment for the resuscitation attempt.
“As the resuscitation progressed she comments that she made phone
calls and answered the phone in connection with the emergency.
“It is believed by the reviewer that on closer examination she contributed
appropriately to the situation and provided important assistance to the
man and members of staff during the resuscitation with little or no training
in many of the procedures involved.”
308. Although any delay in commencing resuscitation is evidently dangerous, I do
not believe that there should be any criticism of the actions of OSG B.
Indeed, it is noteworthy that she encountered this tragedy in the first week of
her new duties in a house block. If, as she claimed, she had received no first
aid training of any kind, she did well to cope with the traumatic events she
encountered.
309. The spokesperson reaches the following conclusions as to the overall
effectiveness of the response when the man was discovered:
“Our review began at the point that OSG A saw him hanging in the
Listeners’ room. Our remit was to review the clinical elements of the three
questions raised by the Ombudsman as documented above.
“We conclude that based on the information provided, he was given swift
and appropriate medical care. However, the incident reports were of a
poor standard and provide limited accurate information. In particular,
there were no time scales, which made the review difficult.
“The interviews provided more appropriate information. However, at times
the transcript was confusing and missed words. The absence of a
specialist in resuscitation at the interview led to many areas lacking
important clarity and left a number of issues that would have provided
invaluable information regarding the events that occurred that night
unchallenged. It also led the reviewer to believe that staff lacked
knowledge and understanding regarding some of the skills they were
performing.”
The comments relating to the absence of a specialist during interviews are of course
a matter for my office and the PCT rather than for the Governor of High Down in
particular, or for the National Offender Management Service in general.
At the final consultation stage, the man’s parents expressed their view, through their
solicitor, that the summary of the spokesperson’s advice on the adequacy of the
treatment he received in prison was inaccurate or misleading. Their solicitor wrote
as follows:
“The report confirms that the spokesperson believed the use or availability of all the
equipment used to assist the man was ‘appropriate in a peri-arrest…and cardiac
arrest situation’. However, earlier the report confirms her advice that the following
equipment, used on him, was not appropriate during a cardiac arrest: saturation
monitor, blood pressure cuff, blood pressure machine. In the event that
80
inappropriate equipment was used, his parents would have sought clarification of the
possible negative consequences for his care. His parents remain confused by the
advice and are disappointed that no steps have been taken to clarify this information
in the report.
“The man’s parents also expressed concerns about the following issues:
1. The failure to provide the spokesperson with access to the Ambulance
AS11 without which she was unable to confirm whether the man’s
heartbeat had returned prior to his departure from the prison to the
hospital.
2. The failure to provide her with staff training records. She has instead
relied on information reported by staff to advise on the adequacy of the
level of training of those involved in his care.
3. The failure to provide her with access to the equipment used to assist
him, without which she confirmed that she was unable ‘to determine
whether the type of equipment alluded to [by staff] was functioning
effectively or met all the current standards in resuscitation’.
4. Her comments that OSG B may not have used the correct procedure
to cut the ligature. The parents would have liked clarification of this
comment, including details of any impact this may have had on their
son’s situation.
5. The parents have confirmed that, above all, they remain concerned
about the inadequacy of the information provided to the spokesperson
and they contend that her findings may have been different had she
been provided with access to appropriate records and equipment.”
310. The report makes the following recommendations:
• A full audit of resuscitation equipment, including the review of access to
different levels of emergency equipment should be undertaken.
• An accurate database containing records of all emergency (first aid)
training given to staff on site should be maintained.
• All staff should attend basic life support training including prison specific
scenarios.
• In accordance with National Offender Management Service’s
recommendations, ensure that Prison Officer Entry Level Training
(POELT) courses not only include basic life support training but also a
suicide scenario such as hanging.
• In accordance with the Department of Health’s publication ‘Toolkit for
Health Care Needs Assessment in Prisons’, carry out a risk assessment to
identify the level and number of people requiring specific training.
• Ensure an appropriate number of prison officers have first aid training.
• In accordance with the NHS Knowledge and Skills framework, ensure all
qualified nursing staff can respond appropriately to emergency situations.
• In accordance with the Department of Health’s publication ‘An Education
and Training Framework for Staff Providing Health Care in Prisons, dated
October 2005’, there should be emergency response officers from either
prison health care workers or prison officers who should be trained to UK
Resuscitation Council Immediate Life Support (ILS) standard or
equivalent. This framework also makes reference to Basic Life Support
training in POELT.
81
• In accordance with the latest guidance from ‘National Health Service
Litigation Authority (NHSLA) advice for Mental Health, May 2009’, it is
advised not only for ILS training of appropriate staff in high risk areas but
also regular emergency drills to take place to practice scenarios and
adequately prepare scenarios and adequately prepare staff for such
emergencies.
• There should be training and education in how to document the events of
a serious incident on an incident statement form.
• It is also suggested that someone suitably qualified in resuscitation and in
the management of medical emergencies is present at the interviews
following this type of incident to ensure accuracy and clarity in the
gathering of information pertaining to clinical incidents.
311. In a statement provided by one of the paramedics who treated the man, a
reference is made to a remark that he was “obviously dead”. The remark was
not attributed to any specific person. The investigation could not discover
which, if any, member of staff at High Down used these words. Neither was
there evidence that this statement had any adverse effect on the speed of
response by the ambulance service. However, all staff who find themselves
in the distressing position of having to respond to a life threatening
emergency must take care to avoid the use of terms that may not be
accurate. Whilst I make no formal recommendation, the Governor and the
PCT may wish to bring the matter to the attention of their staff at High Down.
312. At the consultation stage, the man’s parents expressed their opinion that two
officers should be criticised for entering his cell after he had been found
hanging in the Listener Suite.
313. The Prison Service’s policy for the procedures to be followed when a death of
a prisoner occurs in a prison is set out in Prison Service Order 2710. The
following provisions are made at paragraph 2.6 of that Order:
“Once a death has been verified by a qualified person, a member of
staff must be posted to remain at the scene and keep a record of the
names of all those entering the cell, which must be limited only to
those directly involved in the incident. Pending the arrival of the police,
all relevant evidence must be preserved, including unsent letters
pending in outgoing post and pin-phone records of recent telephone
calls.”
314. I am satisfied that the conduct of the officers in entering the cell was not in
breach of these provisions. I say this because:
• He was declared dead at hospital and not at High Down,
• he hanged himself in the Listener suite and not in his cell.
315. It is not clear why they decided to go into the cell. I surmise that Officer D,
believing that the man was still alive, may have wished to satisfy himself as to
whether there was anything in his cell which would shed light on his
intentions. Whatever their motive, I believe both officers can both be forgiven
if they believed that the area to be sealed for evidential reasons was the
Listener Suite rather than his cell, however erroneous their perception may be
judged in hindsight.
82
316. In any event, my investigation found that both members of staff recognised,
within moments of entering the man’s cell, that they were not permitted to
disturb any of its contents and therefore left after a few moments. There is no
evidence that their entry into the cell had any detrimental effect on the police
investigation. I therefore make no criticisms of their conduct and make no
recommendations in this connection.
Was the man bullied by anyone at High Down and if so, were appropriate
measures taken to deal with the bullies and to maintain his safety?
317. The investigation found evidence that there were five occasions when there
may have been some form of bullying related behaviour in which the man
may have been either an aggressor or a victim. The first was on 4 July, when
he told Officer A that he had been attacked by another prisoner. He said the
attack was related to a tobacco debt. He told the officer he had been
punched on both sides of his head. The officer recorded in his file that she
had seen red marks on both sides of his temple. On this occasion, there was
no evidence that the correct procedures for recording his injuries or for
investigating his claims were followed.
318. The second occasion was the next day (5 July) when he told staff he had
been threatened by other prisoners. Although he mentioned no names,
another prisoner suggested to staff that he had not told the truth about what
had happened. The prisoner suggested that he had gone to another
prisoner’s cell and had intimidated him in order to “get something out of him”.
Although the investigation found no evidence of any formal investigation into
this event, an entry was made in the staff observation book recording that a
Bully Book had been opened in respect of the other prisoner. Nevertheless,
he was moved to another house block as a precautionary measure to afford
him better safety.
319. The third occasion was on 13 July, when he failed to collect his detox
medication. On this occasion, a nurse decided to see him. He told her that
other prisoners had asked him to give them his medication. To avoid being
compromised, he decided not to present himself at the treatment room where
the medication was normally administered. My investigators found no
evidence of any formal investigation into his claims.
320. The fourth occasion was on 19 July when, during the course of his
disciplinary hearing for refusing to return to his cell two days earlier, he
claimed his behaviour was due to threatening behaviour against him by other
prisoners whom he did not name. The investigation found no evidence that
any of his claims were fully investigated or whether the information he offered
in his defence was communicated to staff in the house block to which he was
sent.
321. The fifth and final occasion was on 14 August when he told staff he had again
been threatened. On this occasion he mentioned the name of another
prisoner who had threatened to arrange for him to be harmed once released
from prison. The investigation found that specific measures were taken
against the prisoner concerned and that he was kept isolated for a while in his
cell until the other prisoner was transferred to another house block. A Bully
83
Book was opened on that prisoner. Save for my concern for the need to
isolate bullies rather than their victims, I consider that the measures taken in
respect of him were reasonable in the circumstances.
Conclusions
322. The fact that the man mentioned no names in respect of the first four
instances of bullying described above would have significantly impaired the
ability of staff to investigate his claims. This may explain why it appears no
investigations were apparently carried out. However, although I make no
formal recommendation, the Governor will wish to ensure there is no
complacency on the part of staff in their management of unattributable claims
of bullying by prisoners. The local violence reduction strategy seems to be a
well constructed and effective statement of policy. Staff should be reminded
of the importance of adhering to its provisions, as well as those of PSO 2750.
Were appropriate courtesies afforded to the man’s family after he was
discovered hanging and after his subsequent death at hospital?
323. Here, I examine:
• The actions of the officer in his role as Family Liaison Officer.
• The difficulties and delay in contacting the duty governor after the man
had been found hanging.
• The consequent delay in informing the man’s parents of his condition and
admission to hospital.
• The conduct of the staff from High Down who attended the hospital.
• The level of support offered by the Governor and his representatives to
the man’s parents after his death.
The actions of the officer in his role as family liaison officer
324. The investigation found that, although trained as a family liaison officer, the
officer had not previously carried out the role. At interview, my investigators
asked him to explain how he thought he had conducted himself. He said that,
having taken up his role on 26 August, his first priority was to go to the
Governor’s office where the man’s files were stored and take notes from
some of them. He said he thought his first telephone call to the family would
have taken place at about 2.00pm that day. He told my investigators that the
man’s father “was not there”. He therefore decided to call again later. He
said he eventually got through to him at about 4.00pm. He explained to my
investigators that the purpose of his call was to introduce himself as the FLO,
to say what the job entailed and to arrange to meet the parents in person. At
interview, the officer said he was keen to “help as part of the grieving process
and to present the Prison Service in the best possible way”.
325. The man’s father has said that, when the officer called at 2.00pm, he left a
message on his answerphone but failed to leave a contact number. The
officer said he could not recall that failure.
326. The man’s father has said that, in the same answerphone message, the
officer said he would call again later but did not do so until prompted to do by
the SO. The officer said he rang him back as soon as he “felt he would be
84
in”. When asked how he would know when he would be in, the officer replied,
“I think someone said to me that he’d been trying to contact me and I should
call him. But I had in mind to call him back.” He explained that, in the two
hour period between making his unsuccessful call and getting through to him
on his second attempt, he spent his time gathering more information about
the man. My investigator put to him the suggestion that it might have been
more appropriate to gather the information before making the first call. In
response, he said that he was not aware of any guidance given to him about
time limits during his FLO training.
327. The man’s father has also said that the officer did not offer any condolences
to the family. The officer said he could not remember doing so. When my
investigators put to him that it might have been appropriate to say words to
the effect, “I’m very sorry to hear of your son’s death”, he replied:
“When I was having the conversation over the telephone I wanted to
portray that, I didn’t want to portray sympathy that wasn’t genuine and it
was genuine. But I wanted my sympathy to be related to me wanting to
see him as soon as I could, to being available at any time, which I told him
I was and to let him know that I was trying to work as hard as possible and
I was trying to work as quickly as possible with regard to getting his son’s
effects back to him.
“So I’d been in touch with various parties, the Coroner etc. In my mind I
was trying to be empathic via those avenues, that I was working on your
behalf, that I was really trying to do the best I can to try and resolve it. I
wouldn’t like to comment on my reasons. I feel, looking back now, that’s
what I was trying to achieve.”
328. The man’s father claimed that the officer “stalled, paused and stammered his
way through the call”. The officer told my investigators he was not aware that
he did so. He said:
“I was aware that I felt very emotional and I was very aware of his
emotions and I felt as though I was trying to be as impassive as possible
and I was truly feeling the sadness of the whole situation.”
329. The man’s father claimed that during the telephone call, he told the officer he
wanted to meet with a named member of staff but that the officer did not know
who he was. The officer told my investigators he did not know straightaway,
but by the end of the call he realised the member of staff concerned was the
duty governor who had originally gone to meet the family at the hospital to
which the man had been taken. When asked whether he was aware of this
before he made the call to the man’s father at 4.00pm, the officer said he was
either told this by the SO or had read it in the FLO log.
330. My investigators checked the log and could find no reference to the duty
governor prior to the officer’s appointment as FLO. The log contains four
entries made by the officer on 26 August, timed as follows:
1.55pm – telephone call made to the Coroner’s officer
2.05pm – telephone call to the man’s father
4.25pm – telephone call to the Coroner’s officer
85
4.30pm – telephone call to the man’s father
331. The man’s father said that, in relation to his request for a meeting with the
duty governor, the officer said, “I suppose this week would be nice?” The
officer told my investigators he could not remember saying that and believed
he would not have said it. When my investigators put to him that such a
remark would probably have sounded flippant over the phone, he said:
“It would depend on which way it was said. But I can’t remember. What I
do remember saying is that ‘I want to meet you face to face as soon as
possible’ and the Thursday we were talking in the morning, I was on a late
shift and I was willing to come in my own time to meet him. That’s what I
do remember.”
332. The man’s father said that the officer mentioned how busy he was and how
his head “was all over the place”. The officer replied that he could not
remember using that expression but could remember saying he was very
busy and working on his (i.e. the man’s father’s) behalf.
333. The man’s father reported that when the officer said he was very busy, he –
the man’s father- replied, “I feel really bad for you”. The officer said he could
remember that being said and was surprised because he thought he was
being sarcastic. The man’s father claimed that in response to this remark, the
officer thanked him. The officer told my investigators he could not remember
doing so.
334. The man’s father told my investigators that, at this stage, he activated the
loudspeaker facility on his telephone so that a person who was in the room
with him at the time could hear what was being said. He described this
person as being “gobsmacked” by what he heard. The officer told my
investigators he was not aware of that development and said he had no
comments to make about it.
335. The officer told my investigators that at about 5.00pm that day, he was made
aware of the fact that the man’s father had expressed his dissatisfaction with
the manner in which he had expressed himself during the call and that, as a
result, his role as FLO was terminated. When asked whether he would
conduct himself differently if he had to perform the FLO task again, he said, “I
feel I would have done. I feel as though I would have concentrated less on
the fact gathering and more on the emotional.”
Conclusions
336. While I understand the pressure of the unfamiliar situation in which the officer
found himself, it is very disappointing that this initial contact with the family
went so badly. My investigators found that the two other FLOs – two Senior
Officers - performed their role professionally, competently and, I believe, to
the satisfaction of the family.
86
Recommendation 18
The Governor should consider the merits of requiring newly trained Family
Liaison Officers (FLO) to shadow an experienced FLO prior to being given sole
responsibility in that role for a family whose relative has died in custody.
The difficulties and delay in contacting the duty governor after the man had
been found hanging
337. Governors are required to have in place contingency plans for the
management of serious incidents that may occur by day or night. The plans
must include arrangements for contacting senior managers as quickly as
possible. Each prison has a duty governor rota system under which, in the
event of a serious incident, a senior manager becomes the first point of
contact for staff. The duty governor is responsible for ensuring that the
contingency plans for the particular incident are fully and properly enacted.
Details of contact numbers for duty governors and other senior managers
should be available in the control room (or command centre) in each prison.
338. During the period Friday 22 August – Monday 25 August 2008, a deputy
Governor was effectively in charge of High Down in lieu of the Governor, who
was on leave. He was the nominated duty governor but another governor
agreed to fulfil the responsibilities of duty governor in his stead.
339. The investigation found that staff in the control room were not aware that they
had exchanged duties. At 2.18 am, eight minutes after the man had been
found hanging, they telephoned the supposed duty governor’s number and
gained no response. They then systematically tried to contact the other
senior managers on their list, again without success. At 3.40am, one and a
half hours after the man had been found hanging, the night orderly officer
managed to contact a senior manager who was not on call and told her that
the man had been found hanging and had been taken to hospital. She was
unable to drive to the prison. (In fact there was no requirement for her to do
so as she was not on call.) Instead, she gave advice to the orderly officer as
to what should be done.
340. At 4.07am, nearly two hours after the man was found hanging, the control
room staff managed to contact the duty governor after at least one
unsuccessful attempt.
341. During the course of the investigation, my investigators visited the control
room and examined the quality of its organisation and the systems in place
for the prompt and effective management of an emergency. My investigators
also interviewed one of the Operational Support Grades on duty in the control
room during the night of the incident.
342. The examination of the control room left my investigators with concerns about
its efficiency. It was untidy and lacked organisation. A white board fixed to a
wall in the room seemed to have been used to display information useful in an
incident such as the contact numbers of senior managers. On the day of the
examination it bore the wrong date. The board was positioned behind the
control room staff so that they had to swivel their chairs to be able to view its
contents.
87
343. My investigators also noticed that a number of folders were stored in an open
cabinet near the point where the control room staff normally sat. Each of the
folders contained separate contingency plans for different types of
emergency. However, none of the folders was labelled. Thus, control room
staff were unlikely to be able quickly to extract the correct folder for the
particular emergency facing them.
344. My investigators were told that one such folder contained contact numbers.
The responses given to my investigators during interviews suggested that
some of the telephone numbers recorded in the control room folder may have
been incorrect. The Operational Support Grade was unable to confirm that.
She also told my investigators that training exercises in the management of
serious incidents, which involved control room staff, were rarely carried out at
High Down.
Conclusions
345. On the day of examination, the control room was untidy. There was no sense
of ownership of the room. The effectiveness of its function as a key
‘command centre’ of the prison was impaired by its disorganisation.
Recommendation 19
The Governor should ensure that systems are in place in the control room for
the recording and display of accurate and up to date contact details for all
senior staff and that contingency planning exercises test this.
Recommendation 20
The Governor should consider the merits of including amongst the
responsibilities of the duty governor that of visiting the control room every
day in order to check the accuracy of the information recorded as well as its
tidiness and organisation.
The consequent delay in informing the man’s parents of his condition and
admission to Epsom General Hospital
346. It fell to the duty governor to take responsibility for informing the man’s
parents that he had been found hanging and that he had been admitted to
hospital. He did not do so until 6.40am that morning. He told my
investigators that as soon as he had been contacted by the control room at
4.07am, he first called the deputy governor to brief him on events and then
left for the prison, arriving at 5.50am. There was a further delay of 50 minutes
before he called the family.
347. At interview, he explained that he spoke to the man’s father and said that his
son had been found hanging and was in a critical condition in the intensive
care unit at hospital. He agreed to meet the family at the hospital. When
asked whether the father said anything about how he would get to the
hospital, or not wanting to drive because of his distress, he said he did not. In
other investigations, I have found that prisons have offered to arrange taxis.
88
It might therefore have been appropriate for him to have offered to organise a
taxi to take the father to the hospital at public expense.
Recommendation 21
The Governor should ensure that in any circumstances which lead to a
prisoner’s emergency admission in hospital, every effort is made to assist the
prisoner’s family to visit him. If necessary, the prison should consider
providing a taxi for this purpose, paid for at public expense.
348. At interview, the duty governor said, “The only thing that I would say I would
have done sooner, had I been contacted earlier, was notify the next of kin.”
He explained that the delay of about 55 minutes between arriving at the
prison and telephoning the parents was because he was concerned to gather
up to date information about events before making the call. He telephoned
the hospital in order to get a briefing on the man’s condition. He had difficulty
getting through to the ward and only found out about his condition when he
was telephoned by a police officer who was in attendance. He said he had no
difficulty in ascertaining the parents’ contact details.
Conclusions
349. I judge as unacceptable the two hour delay incurred by the confusion in the
control room as to who was the duty governor and by the fact that contact
details of some of the senior managers were inaccurate. This had the most
unfortunate effect of incurring an equally unacceptable delay in informing the
man’s parents of his condition. I believe that the time taken by the duty
governor to gather sufficient information before calling the family was
reasonable in the circumstances. However, the combined effect of both these
delays was the source of much pain for the family. This situation must not be
allowed to recur.
Recommendation 22
The Governor should review his contingency plans for the management of a
life threatening emergency involving a prisoner in order to ensure that
arrangements are in place for informing the next of kin as a matter of extreme
urgency.
The conduct of the staff from High Down who attended the hospital
350. The man’s father told my family liaison officer he was concerned about the
manner in which the staff who attended the hospital conducted themselves.
He claimed the governors and officers “all stood together in a circle, huddled
together”. He said they were all holding different folders and he thought they
were checking their notes and “getting their stories straight”. He also
questioned whether the SO felt uncomfortable about her attendance at the
hospital in uniform.
351. In this connection, my investigators interviewed the duty governor and the
SO, both of whom attended the hospital. In response to the father’s
comments, the duty governor said:
89
“There is no story to join really. We were really there for support. I was
aware that it’s a very personal time for the family. I felt particularly as we
knew that the man was still alive for a certain period of time and I suppose
I felt that I should be there for when he was declared dead if that were to
happen and certainly it seemed as though he would be declared dead by
the end of the night or by some stage in the morning. And I felt it would
have been completely inappropriate for the family to be given that news
and to find that there was no-one there from the prison.”
352. At her interview, the SO said:
“I’d said to the family, I’m going to be in here for as long as you want me to
be. If you’ve got any questions, just come and approach me and I’ll see
what I can do.”
353. When asked what time she left the hospital, she said:
“I’m going to say about half two, quarter to three or something. The man’s
dad actually asked us to leave. He approached us after and asked if we
were there because we had to be or because we were there for the family.
We said well both really, we’ve done what we have to but we’re here in
case any questions need answering and he said oh in that case I’d prefer
it if you left so we said ok, fine.”
354. My investigators put to the SO the question raised by the man’s father about
her wearing uniform at the hospital. In response, she said:
“I don’t recall feeling uncomfortable about being in uniform. My main
concern at that time was to get there and offer support to the family.
Whilst on duty in the prison it is standard practice for me to wear uniform
as it was also for the two police officers at the hospital. Had there been a
Family Liaison Officer on duty, they also would have in uniform unless
they had come from home.”
355. At the consultation stage, the man’s parents repeated their concern about the
presence of uniformed officers in the hospital before and after their son died.
They thought that this might have had the effect of “exciting the curiosity” of
other members of the public who were present in the vicinity. They also felt
that it was wholly inappropriate for staff to stand close to their son’s bed.
They considered that the staff behaved insensitively.
Conclusions
356. The parents’ concerns are entirely understandable. In such tragic and
distressing circumstances, it is clearly encumbent on Prison Service staff to
draw the right balance between maintaining security and showing appropriate
courtesies and sensitivities to the prisoner, his family, the hospital authorities
and other members of the public. The man presented no threat to security
and so it was arguable that the number of Prison Service staff in the ward
could have been reduced to an absolute minimum. I recognise that
uniformed staff were a particular source of embarrassment and distress to
them, however the option of wearing civilian clothes was not available to
them.
90
357. I believe that the Governor of High Down will appreciate the value of the
feedback the man’s parents have given and will wish to consider what specific
measures can be added to his contingency plans to minimise the level of
distress that the presence of uniformed prison staff can unintentionally cause.
The level of support offered by the Governor and his representatives to the
man’s parents after his death
358. The Governor wrote a letter of condolence to the man’s parents shortly after
his death. The letter carried an incorrect spelling of the man’s name. This
was most unfortunate, especially in light of the circumstances that had led to
the replacement of the officer as FLO. However, as soon as the Governor
realised the mistake, he telephoned them to offer his apologies.
359. The Governor offered to pay the full costs of the man’s cremation, which took
place on 8 September 2008. A FLO attended on the Governor’s behalf.
360. Two days later, the man’s parents visited his cell and the Listener suite under
arrangements made by the FLO. They also collected his belongings.
Conclusions
361. The unfortunate matter of the letter aside, I believe the Governor and the FLO
offered the man’s parents appropriate support after their son’s death.
91
PRINCIPAL CONCLUSIONS
362. This report includes a number of critical observations on High Down. Some
of my recommendations repeat those made in earlier reports.
Healthcare
363. The authors of the Clinical Review raise no significant criticisms of the
manner in which the man’s healthcare needs were managed, making the
point that there were no specific concerns raised about his mental health until
shortly before his death. There was no evidence that, at the time of his death,
he was suffering from a depressive illness nor any other major disorder. (At
the consultation stage, his parents drew attention to their underlying concerns
about their son’s mental state in relation to his previous disclosures that he
had attempted suicide and committed acts of self-harm. They believe that
these concerns, together with his diagnosis of ADHD and the absence of
medication to treat it, his use of the Samaritans and Listeners Scheme, his
account of loss of parents and partner, along with the resulting referral to the
Mental Health In-reach Team, meant that he did present a raised risk of
suicide at the time of his death.)
364. It is recognised that the man gave staff inconsistent and confusing information
about his medical and psychiatric history in the early days of his sentence, but
it should have been possible for his disclosures to be verified by reference to
previous records. This systemic failure is too often revealed in the course of
my investigations. I urge the National Offender Management Service to act
upon the recommendations I and the clinical review team make in this regard.
365. The fact that the mental health in-reach team returned the man’s referral form
for correction, rather than acting upon it, is a matter of concern. Although I
make no formal recommendation on this matter, I urge the mental health in-
reach team to do all they can to protect against a repetition.
Management of the man’s risk of self harm and suicide
366. Although I give credit to SO A for opening an ACCT form on 20 August, the
first and only case review held the next day was not conducted by a multi-
disciplinary panel in accordance with the provisions of PSO 2700. The
recommendation I make about this matter was made by Her Majesty’ Chief
Inspector of Prisons in two successive inspection reports.
367. When the man asked to speak to a Listener and then to the Samaritans
during the night, no consideration was given to the heightened risk of self
harm or suicide he may have presented. This is contrary to the provisions of
paragraph 31 of the local suicide prevention strategy.
368. OSG A seemed oblivious of the local orders for the conduct of pegging and
timing of pegging. Instead of following laid down procedures, he carried out
his checks in a predictable manner.
92
369. I am also critical of him in respect of the discrepancies between the timing of
the entries he made in the man’s ACCT ongoing record during the night and
those shown on the CCTV footage.
The design and use of the Listener suite
370. Although I do not criticise the decision to allow the man to telephone the
Samaritans from the Listener suite, the fact that the suite had been attributed
the status of a multi-purpose room had the effect of eroding its importance as
a facility for the care of at-risk prisoners. In my view, insufficient attention was
paid to furnishing the room for that purpose in keeping with the provisions
described in PSO 2700 for Time Out Rooms. The term Listener suite is not
unique to High Down, but it is unhelpful as it does not tally with terminology
used in the PSO.
The standard of record keeping
371. The investigation found several instances of poor record keeping by
substance misuse nurses and by discipline staff. Perhaps the most
significant example was that relating to the entry made by OSG A in the
man’s ACCT ongoing record at 2.00am, which proved to be grossly
inaccurate (by 53 minutes). I have drawn attention to examples of poor
record keeping High Down in earlier investigation reports.
Effectiveness of the response to the discovery of the man hanging
372. The review conducted by Back to Life Ltd on behalf of the local PCT
concluded that the man was given swift and appropriate medical care.
However, the incident reports were of a poor standard and provided limited
accurate information. In particular, there were no time scales mentioned in
the reports.
Bullying related behaviour
373. The investigation found evidence that there were five occasions when there
may have been some form of bullying related behaviour in which the man
may have been either an aggressor or a victim. On four out of five occasions,
he refused to name the alleged bullies. This may explain why no
investigations were carried out. The local violence reduction strategy seems
to be a well constructed and effective statement of policy. Staff should be
reminded of the importance of adhering to its provisions, as well as those of
PSO 2750.
The actions of the officer in his role as family liaison officer
374. I have criticised the officer’s initial contact with the man’s father, and believe
that the decision to terminate his appointment as FLO was entirely
appropriate. My investigators found that the two other FLOs - Senior Officers
- performed their role professionally, competently and, I believe, to the
satisfaction of the family.
93
The difficulties and delay in contacting the duty governor after the man had
been found hanging
375. Because staff on duty in the control room at High Down on the night of the
incident were not aware that the role of duty governor had passed from one
senior manager to another, there was a two hour delay in contacting the
correct person after the man was found hanging, and a further delay in
informing his parents. The combined effect of both these delays was the
source of much pain for the family. Such a situation must not recur.
376. An examination of the control room found it to be untidy. There was no sense
of ownership of the room. The effectiveness of its function as a key
‘command centre’ of the prison was impaired by its disorganisation.
The conduct of the staff from High Down who attended the hospital
377. I believe that the Governor of High Down will appreciate the value of the
feedback the man’s parents have given and will wish to consider what specific
measures can be added to his contingency plans to minimise the level of
distress that the presence of uniformed prison staff can unintentionally cause.
The level of support offered by the Governor and his representatives to the
man’s parents after his death
378. The Governor wrote a letter of condolence to the man’s parents shortly after
his death. Very unfortunately, the letter included a misspelling of his name.
379. With that exception, I believe the Governor and the FLO offered them
appropriate support after their son’s death.
94
LIST OF RECOMMENDATIONS
To the National Offender Management Service
1. There should be one unified health record within the prison and this should
contain information from health and substance misuse teams. The same
record should continue during a period of custody and be available at
subsequent periods of custody. The National Offender Management Service
should ensure that this record, as well as the core prison record relating to
prisoners’ previous periods of imprisonment, is available at, or very close to,
the point of any subsequent admission to prison. Where the unified health
record or core prison record is received after initial healthcare screening
reports have been completed, the information in those reports should be
verified against the details contained in the health and prison records. Staff
should consider whether to take any action in response to any new
information contained therein. Healthcare staff should request a copy of any
medical records relating to the periods spent by prisoners in police custody
and should ensure that all significant information contained therein is
recorded in the prisoner’s unified health record.
The National Offender Management Service has accepted this
recommendation and said,
“NHS Connecting for Health has a programme team in place to facilitate the
national IT programme. TPP, system one aims to be rolled out in England by
2010 (gateway reference 11812) and will ensure a unified health record.”
The Primary Care Trust commented as follows:
“There is already one unified health record used by substance misuse and
healthcare. Previous records are kept in an archive room but locating
previous records is dependent upon the accuracy of the information provided
by prisoners, e.g. name/alias. TPP System One, an electronic record, is
being deployed in all Surrey prisons commencing from February 2010. This
record will be based on NHS numbers rather than on prison numbers.
Continuity of care should therefore be greatly improved.”
2 The National Offender Management Service should ensure that judgements
as to risk of self-harm or suicide take into account historical information in
prisoners’ records.
The National Offender Management Service has not accepted this
recommendation. The following response was received:
“PSO 2700 already requires staff to take account of all available information
when assessing the level of risk presented by a prisoner at risk of suicide or
self harm. Chapter 4.16 sets out the requirements for checking for risk in
95
previous custody and Chapter 4.17 deals with other sources of risk
information or assistance concerning prisoners. ACCT Case Manager
training includes specific modules on estimating and managing immediate risk
of suicide, which covers levels of risk, mental health awareness and
substance misuse. Before (or of need be after) undertaking an ACCT
assessment, the Assessor is asked to collect risk pertinent information from
the core record, wing file and healthcare staff.”
To the Governor and Primary Care Trust
3. The Governor and PCT should ensure that all staff are aware of and follow
the provisions of Annex 8G of PSO 2700 which clearly states that an ACCT
form must be opened whenever a prisoner is found to have self-harmed.
This recommendation has been accepted. The following response was
received from the Prison Service:
“Safer Custody have delivered refresher ACCT awareness training for
healthcare/In-reach staff. Aide memoires are provided for all staff receiving
ACCT awareness training. National trainers recently provided a workshop for
case managers and assessors. They have been invited back in the near
future. ACCT awareness training is scheduled for training mornings as part of
the prison training plan. The provisions of annex 8G are part of ACCT
awareness training.”
The PCT responded as follows:
“This is already current policy. Staff will be reminded at clinical supervision
and team meetings. All healthcare staff attend foundation ACCT training and
this is reported by safer custody at the bi-monthly clinical governance
meetings.
4. The Governor and the PCT should remind their staff of the importance of
completing a form F213 or, if necessary, a form F213SH, whenever a
prisoner sustains an injury, no matter how minor.
This recommendation has been accepted. The following response was
received from the Prison Service:
“The suicide prevention coordinator investigates all incidents in the prison and
highlights where F213/SH have not been completed. The deficiencies are
passed to the Unit manager for rectification. The results of the investigations
are fed into the Senior Management Team and Safer Custody Meetings. This
system of raising awareness has improved the completion rate for 213s. To
back this up a Governor’s Information Notice will be published informing staff
of the requirement to complete F213/SH. The suicide prevention policy
(available on the intranet in all staff accessible areas of the prison) also
highlights the requirement to complete F213/SH. A self-harm incident pack
has been produced and once the new incident reporting form has been
printed, will be available in all areas of the prison.”
The PCT responded as follows:
96
“This is already current policy. Staff will be reminded at clinical supervision
and team meetings.”
To the Primary Care Trust
5. The PCT should instruct its substance misuse staff to make entries in
prisoners’ clinical files whenever they see prisoners, especially in relation to
detoxification issues and events.
This recommendation has been accepted. The PCT responded as follows:
“It is the duty of all staff to comply with the NMC Code of Conduct of record
keeping. Regular training sessions in record keeping have been in place for a
number of years. Considerable improvement has already taken place in
record keeping on the stabilisation unit. Audits within the last 6 months have
demonstrated improvement.”
6. Healthcare and CARATs staff must take appropriate action in response
to information received relating to prisoners’ healthcare needs or
ongoing health conditions. In addition, whenever a prisoner discloses
details of medication they were receiving in the community or the name
of their GP, such information must be communicated to healthcare staff
who must take steps to verify that information as soon as possible.
Such steps are necessary to ensure that provided with continuity of
care.
To the Governor
7. The Governor should, in keeping with the provisions of PSO 1025, ensure
systems are in place to guarantee that PERS are always seen and studied by
reception staff, and that comments in PERs as to risk are taken into account
by staff when judging how best to care for and support individual prisoners.
Managers should carry out regular compliance checks.
No response was received in relation to this recommendation.
8. The Governor should ensure that Reception staff are aware of the provisions
of PSO 2700, especial in relation to the use and handling of Prisoner Escort
Records (paragraphs 4.3 and 4.4 of that Order refer).
The Governor should ensure that ACCT case reviews are conducted by multi-
disciplinary panels in keeping with the provisions of Annex 8G of PSO 2700.
This recommendation has been partially accepted. The following response was
received:
“Every effort is made by the case managers to ensure that reviews are mutli-
disciplinary. This is not always achievable due to the size of the prison. If
unable to attend, interested parties are invited to submit a written or emailed
report. If required, the review will be adjourned for the staff to be phoned for
further input.”
97
9. The Governor should remind his staff that, whenever a prisoner self-harms,
the next of kin should be informed in keeping with the provisions of Chapter
13 of PSO 2700. The Governor should also remind his staff of the importance
of ensuring that key information provided by he next of kin, especially that
which may relate to a prisoner’s physical or mental health, should be
recorded in the prisoner’s ACCT record if one has been opened and shared
with healthcare staff as soon as possible.
This recommendation has been partially accepted. The following response
was received:
“PSO 2700, chapter13.3.3 states that next of kin should be informed unless
the prisoner does not give consent or the caremap indicates otherwise. We
will produce a form to be included within the ACCT document where a
prisoner indicates his wishes.”
10. The Governor should remind his staff of the need to rub-down search any
prisoner allowed to leave his cell at night unless, in the particular
circumstances they face, it would be inappropriate to do so.
This recommendation has been accepted. The following response was
received:
“Staff currently adopt this approach. However, this is not reflected in the
Local Security Strategy (LSS) or night orders. The Security manager is
reviewing the LSS and this guidance will be included. The night orders will be
amended accordingly. In the interim, the Head of Safer Custody will inform all
night managers.”
11. The Governor should remind his staff of the importance of adhering to the
provisions of paragraph 31 of his local suicide prevention strategy which
requires them to be alert to the possible heightened risk to a prisoner when
he asks to use the Samaritan’s telephone.
This recommendation has been accepted. The following response was
received:
“We are unsure of the reference to paragraph or page 31. There is no
reference to a heightened risk when asking for the Samaritans’ phone. There
is however a need to include this in the policy which will be updated.”
12. The Governor should ensure that the full provisions of his Local Operating
Procedure for night procedures are both known and complied with by all
those staff who are likely to be on duty in the prison by night. Special
emphasis should be place on pegging procedures.
This recommendation has been accepted. The following response was
received:
“Night staff sign for a copy of their night orders at the commencement of their
shift. The Night Orderly Officer ensures compliance.”
98
13. The Governor should remind his staff of the importance of ensuring that
checks of prisoners – especially those considered to be at risk of self-harm or
suicide – are not carried out on a predictable basis.
This recommendation has been accepted. The following response was
received:
“This will now be included in case manager training and in the Suicide
Prevention policy.”
14. In conjunction with Prison Service Headquarters, the Governor should
consider the merits of re-designating all Listener suites as Time Out Rooms.
This recommendation has not been accepted. The following response was
received:
“The Governor can designate his cells in whatever way he wishes and does
not need the agreement of Safer Custody and Offender Policy Group or
Prison Service Headquarters.”
15. The Governor should ensure that clear instructions for monitoring prisoners
whilst they are in a Time Out Room are included in his local Suicide
Prevention Procedural policy. This is especially important where prisoners
subject to ACCT procedures are concerned.
This recommendation has not been accepted. The following response was
received:
“High Down does not have Time Out rooms. The problem with the Samaritans
phone signal/reception has been rectified by the installation of boosters.
Prisoners do not now have to use a listening room to call the Samaritans.
The room is only used when Listeners are present.”
16. The Governor should remind staff of the importance of ensuring that
contemporaneous, accurate and legible entries are made in prisoners’ core
files, especially in ACCT forms. Appropriate training should be available to
those staff who may require it.
This recommendation has been accepted. The following response was
received:
“Safer Custody team conduct ACCT management checks daily. Any
deficiencies are highlighted to Unit managers for rectification. The findings
are fed into the SMT and Safer Custody meetings for analysis and action.
Houseblock managers also carry out quality checks of entries. This is also
emphasised during refresher training.”
17. The Governor should consider the merits of requiring newly trained Family
Liaison Officers (FLO) to shadow an experienced FLO prior to being given
sole responsibility in that role for a family whose relative has died in custody.
99
18. The Governor should ensure that systems are in place in the control room for
the recording and display of accurate and up to date contact details for all
senior staff and that contingency planning exercises test this.
This recommendation has been accepted. The following response was
received:
“Nothing currently in place. Every quarter commencing April, the Governor’s
secretary will request current contact details for all senior staff, including
pager numbers. This contact list will be shared with the control room.
Security Governor to test contacting senior staff.”
19. The Governor should consider the merits of including amongst the
responsibilities of the duty governor that of visiting the control room every day
in order to check the accuracy of the information recorded as well as its
tidiness and organisation.
In rejecting this recommendation, the prison explained that the responsibility
for visiting the control room each day rests with the Security manager.
20. The Governor should ensure that in any circumstances which lead to a
prisoner’s emergency admission in hospital, every effort is made to assist the
prisoner’s family to visit him. If necessary, the prison should consider
providing a taxi for this purpose, paid for at public expense.
This recommendation has been partially accepted. The following response
was received:
“There is no requirement for the prison to provide transport for families to visit
prisoners in hospital. If it is believed that the prisoner could die, or the family
would find it difficult to attend the hospital, then the Duty Governor may offer
assistance.”
21. The Governor should review his contingency plans for the management of a
life threatening emergency involving a prisoner in order to ensure that
arrangements are in place for informing the next of kin as a matter of extreme
urgency.
This recommendation has been accepted. The following response was
received:
“Contingency planning has already been set for 2010 to 2011. However, the
Death in Custody contingency plan and Local Operating Procedure will be
reviewed and updated.”
Recommendations made by the spokesperson of Back to Life as part of the
clinical review
(The response from the PCT is shown below each recommendation)
• A full audit of resuscitation equipment, including the review of access to
different levels of emergency equipment should be undertaken.
100
“Accepted. Surrey Ambulance Service recommended our resuscitation
equipment and advice on updates of equipment. We will request they review
our equipment again.”
• An accurate database containing records of all emergency (first aid) training
given to personnel on site should be maintained.
No response was received for this recommendation.
• All personnel should attend basic life support training including prison specific
scenarios.
“Accepted. All NHS staff attend basic life support as part of PCT induction.
Annual updates are carried out as part of mandatory training schedule which
is linked to KSF appraisal and Personal Development Plans.”
• In accordance with HM Prison Service’s recommendations, ensure that
POELT (Prison Officer Entry Level Training) courses not only include basic
life support training but also a suicide scenario such as hanging.
No response was received for this recommendation.
• In accordance with the Department of Health’s publication ‘Toolkit for Health
Care Needs Assessment in Prisons’ carry out a risk assessment to identify
the level and number of people requiring specific training. Ensure an
appropriate number of Prison Officers have first aid training.
“Accepted with regard healthcare staff. The NHS is not responsible for first
aid training for all officers. The Prison Service has its own training
department. Basic life support and defibrillator training is provided for officers
working in healthcare permanently or on the stabilisation unit in conjunction
with the training for healthcare staff.”
• In accordance with the NHS Knowledge and Skills framework, ensure all
qualified nursing staff can respond appropriately to emergency situations.
“Accepted. Each member of staff has KSF appraisal and a Personal
Development Plan.”
• In accordance with the Department of Health’s publication ‘An Education and
Training Framework for Staff Providing Health Care in Prisons, dated October
2005’, there should be Emergency Response Officers from either Prison
Health Care workers or Prison Officers who should be trained to UK
Resuscitation Council Immediate Life Support (ILS) standard or equivalent.
This framework also makes reference to Basic Life Support training in
POELT.
“Accepted. Hotel 2, which is the most senior nurse on duty, is emergency
responder per shift. They coordinate the shift ad respond to emergencies. If
there happens to be more than one emergency at the same time, Hotel 2 will
ask Comms via radio, to contact Hotel 1, the lead nurse in the inpatient
department, to attend the second emergency.
101
“All staff are trained in basic life support.”
• In accordance with the latest guidance from ‘National Health Service
Litigation Authority (NHSLA) advice for Mental Health, May 2009’ it is advised
not only for ILS training of appropriate staff in high risk areas but also regular
emergency drills to take place to practice scenarios and adequately prepare
scenarios and adequately prepare staff for such emergencies.
“Accepted. The guidance which is based on the National Patient Safety
Agency (NPSA) Rapid Response Report 2008/RRR010 states that training
includes regular practices where feasible. There is a programme in place to
learn from emergencies that happen on a daily basis in a local prison.”
• There should be training and education in how to document the events of a
serious incident on an incident statement form.
102