Individual at Exeter

Investigation into the death of a man
at HMP Exeter in July 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
This is the report of an investigation into the circumstances surrounding the death of
a man. He was found hanging in his cell and died four days later without regaining
consciousness. He had been in prison for less than a fortnight. I offer my sincere
condolences to his family. I apologise for the delay issuing this report and any
additional distress it may have caused them.
The man had struggled with alcohol and substance misuse for several years. His
addiction was at the root of his offending behaviour and he was not a stranger to
prison. His addictions also affected his health. He suffered from depression and
attention deficit hyperactivity disorder (ADHD) and in 2008 he required hospital
treatment for an infection in his heart.
The investigation was led by one of my colleagues. The Ombudsman’s appointed a
family liaison officer. She acted as a contact point for the man’s mother during the
investigation.
A clinical reviewer from the local Primary Care Trust undertook a clinical review into
the medical care received by the man in Exeter. I am grateful to him for his
assistance. I am also grateful to the liaison officer for Exeter prison and to the staff
and prisoners at Exeter for their co-operation with this investigation.
The man received a high standard of care while at Exeter. I am pleased to say that
the emergency aid offered to him was exemplary. I am however critical of the
unacceptable standard of family liaison provided by Exeter. I make five
recommendations and highlight two areas of good practice.
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 June 2010
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CONTENTS
Summary
The investigation process
HMP Exeter
Key events
The prison’s response to finding the man hanging
What other prisoners said
Issues considered during the investigation
- Management of the man’s risk
- The clinical care offered to the man
- The prison’s response to finding the man hanging
- Issues raised by the man’s family
Conclusion
Recommendations
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SUMMARY
The man was a 37 year old man who had been addicted to alcohol and illegal
substances for many years. He suffered from attention deficit hyperactivity disorder
(ADHD) and depression. He was arrested on 22 June 2009 and remanded into HMP
Exeter on 24 June. He had three children. At the time of his arrest he was not
allowed access to his children, a fact which distressed him greatly.
In Reception at Exeter the man expressed anxiety that he would be at risk from other
prisoners. He explained that he had given evidence at a trial several years ago in
his local community and he was worried that he would be regarded as a ”grass”. He
remained anxious about this for the duration of his time in Exeter.
The man was located in cell B3/1. This cell is close to the wing office and allowed
staff the opportunity to observe him. Wing staff told the investigator that they did not
see any other prisoners go to his cell or harass him in any way. One officer who had
known him on previous sentences told the investigator that his behaviour was very
different on this sentence. He described him as very anxious, with obsessive and
paranoid thoughts. He had not tried to harm himself when he was in prison before.
A prisoner who spent the most time with the man between 24 June and 4 July, told
the investigator that the man was anxious to obtain a newspaper clipping that he
said proved he was not a ”grass”. He said the man was worried about other
prisoners but he had not thought he was at risk of harming himself.
The man was examined by three doctors and four members of the primary care
nursing staff during the 12 days he spent in Exeter. The clinical review concludes
that the clinical care he received was appropriate. The review makes a single
recommendation about the legibility of entries in the clinical record.
At about 3.45pm on Sunday 5 July, the man was found hanging from his cell light by
his shoelaces. Staff responded in a timely and highly effective manner. He was not
breathing when he was found but staff and paramedics managed to re-start his
heart. He was taken to hospital but sadly he died there without regaining
consciousness.
Wing staff and prisoners on B wing reported that they had received appropriate
support in the aftermath of the man’s death. I raise a concern that healthcare staff
may not have the same level of care extended to them.
I am satisfied that the man was looked after well by wing staff and healthcare staff. I
conclude that his attempt to hang himself could not have been reasonably foreseen
or prevented by staff. Unfortunately the liaison provided to the man’s mother by the
prison was not of a high standard. The family found it hard to contact their liaison
officer and a delay in the prison paying for the funeral meant they were subjected to
unwelcome intrusion from the undertakers at a very difficult time for them. I make a
recommendation that I hope will help to prevent such events from occurring after any
future deaths at Exeter.
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THE INVESTIGATION PROCESS
1. I was notified of the man’s death on 9 July 2009. The investigation was allocated
to an investigator the same day. Notices were issued to staff and prisoners at
Exeter telling them that an investigation would be taking place, and inviting those
who wished to see the investigator to make themselves known. She wrote to the
Coroner and spoke to a Detective Sergeant from Exeter CID.
2. The investigator visited Exeter on 15 July. She met with the Governor, the prison
liaison officer, and a Detective Sergeant. She visited the cell where the man
hanged himself and spoke informally to staff. She collected copies of his prison
record and copies of other records associated with his death.
3. The investigator returned to Exeter on two occasions in July and November 2009
and interviewed 13 members of staff and three prisoners. She also spoke by
telephone to a substance misuse nurse who had worked with the man in the
community.
4. A clinical review of the man’s medical care was commissioned from the local
Primary Care Trust (PCT). The clinical reviewer, a General Practitioner
employed by the PCT, undertook the review. His report appears as an annex to
this report.
5. One of the Ombudsman’s family liaison team contacted the man’s mother by
telephone. She explained the nature and purpose of the investigation and invited
the family to ask any questions or raise any issues about the man’s time in Exeter
prison. The man’s mother did not raise any concerns about his treatment in
Exeter but said she was upset, angry and frustrated by the failure of services in
the community to section him under the Mental Health Act for his own safety.
She said that prior to being sent to HMP Exeter she had been extremely
concerned about his mental health.
6. The man’s mother said she was upset that no member of staff from Exeter had
attended his funeral. She had found the contact she had with one of the prison
chaplains at the hospital very helpful. She also experienced great difficulty in
contacting the prison to arrange payment of the funeral expenses. The prison
had properly offered to meet the cost of the funeral but a subsequent lack of
communication from the prison family liaison officer led to her receiving frequent
and distressing requests for payment from the funeral directors. Despite the best
efforts of the Ombudsman’s family liaison officer to contact the prison family
liaison officer the situation was only resolved when another of my investigators
who was visiting the prison spoke directly to him.
7. In response to the draft report, the man’s mother commented that she felt
strongly that information highlighting that he was at risk of self-harm should have
accompanied him to prison. The family believe that this lack of information
sharing was a significant failing on the part of the community agencies involved
with his care.
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HMP EXETER
8. HMP Exeter is a Victorian prison dating back to 1850. It is located near the city
centre and holds adult male remanded and convicted prisoners and young adult
males between the ages of 18 and 21 on four wings. The prison has an
operational capacity (maximum overcrowded capacity) of 533. It is designed in
the Victorian radial style with wings going out from a ‘centre’. There is an office
on the centre that is used by the orderly officers who are responsible for the daily
operation of the prison. B wing, where the man was located, is the induction and
first night centre. There is a large purpose built healthcare centre with 21 in-
patient beds.
9. In her report of an unannounced follow up inspection in October 2007, Her
Majesty’s Chief Inspector of Prisons found that Exeter was experiencing many of
the pressures of an overcrowded prison system. She reported that population
pressures meant that not all new prisoners could be held on the first night centre.
The investigator found that staff continued to be frustrated by this in July 2009.
They were concerned about the impact overcrowding was having on their ability
to keep new prisoners properly supported during their initial period in custody.
10. In their 2008 report (the most recent one published) the Exeter Independent
Monitoring Board (IMB – a group of independent volunteers who monitor life in
their local prison), concluded that there were a number of dedicated and
professional staff working at Exeter and that staff/prisoner relations were good.
The IMB remarked too that the combination of Victorian buildings and high
prisoner numbers provided enormous challenges for staff to keep prisoners safe
and purposefully occupied.
11. There have been six apparently self-inflicted deaths at Exeter since the
Ombudsman assumed responsibility for investigating all deaths in prison in 2004.
One of these occurred since the man died, in November 2009. In the reports of
the two apparently self-inflicted deaths immediately before his death, in 2007, I
recommended that a hot debrief be held in the aftermath of a death in
accordance with PSO 2710 and PSO 8150, an emergency code system be
introduced and that prisoner’s previous medical records be sought to improve
continuity of care. I am pleased to see that all three happened in this case.
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KEY EVENTS
12. The man was arrested on 22 June 2009 and taken to a Police Station. He
appeared at Magistrates Court on 24 June. The prisoner escort record (PER)
form showed risk indicators for drug/alcohol addiction, self-harm, violence and
health. The explanation section reads, “previous for self-harm, claims to be on
Warfarin”. (Warfarin is an anticoagulant used to prevent blood clots.) The man
was remanded into custody and taken to Exeter prison the same day.
13. On arrival at Exeter, the man was taken to Reception where a nurse completed
his first reception health screen. He told the nurse that he had been homeless
for the previous year. He had last been in Exeter in June 2008. The man said
that he had seen a doctor and was being treated for depression and ADHD. He
said he was taking dexamphetamine (for ADHD), aspirin and Warfarin. He said
that his community nurse worked at the headquarters of the Drug and Alcohol
Team.
14. The man had a black eye and told the nurse that this had happened during his
arrest by police. He also reported chest pain and said this was because he had
a “hole in his heart valve”. He told the nurse that he had spent a month in
hospital because of his heart problems. Despite this he is recorded as saying
that he had no concerns about his health. He admitted to drinking four to six
litres of cider daily but said he no longer used drugs. He said he was not
receiving any medication for any mental health problems and said that a
psychiatrist had confirmed he was of sound mind at a child custody hearing on
17 June.
15. The man said he was very angry but denied any suicidal thoughts. The nurse
recorded, “inmate appears angry at present, difficult to express his feelings”. In
the planned action section (of the first reception health screen), he referred the
man to the prison doctor (because of his physical health) and to CARATS
(counselling, advice, referral and throughcare service – the service which
provides the non-clinical treatment needs for prisoners with substance misuse
issues) for his substance misuse. The nurse wrote that the man could share a
cell but “with discretion as angry at present”.
16. The nurse and an officer completed a Cell Sharing Risk Assessment (CSRA)
form for the man. The officer wrote that the man was fearful for his own safety
and feeling stressed and agitated. He was offered the opportunity to be located
on the vulnerable prisoners wing but declined. The officer concluded that the
man presented a high risk to anyone sharing his cell. The nurse also concluded
that the man presented a high risk to a cellmate. He wrote on the form that he
appeared very angry, feared for his own safety and wanted to be located as a
vulnerable prisoner. Because of the high risk rating the form was then referred to
the duty reception officer. The duty reception officer concluded that the man
needed a period to calm down as he was very angry and could be a danger to
others. He was recommended for a single cell.
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17. Also whilst he was in Reception, the man signed a consent form allowing staff in
the Devon Prison Health Partnership to contact agencies in the community and
obtain information about his healthcare prior to entering prison.
18. Immediately afterwards the man was reviewed by a prison doctor. The doctor
completed an initial medical assessment form. He wrote that the man had drunk
to excess for “a long time”. The man told him that he had suffered fits when he
had stopped drinking previously. The man said that he had a hole in one of the
valves in his heart and had suffered “mini strokes” in 2008. He said that he was
taking Warfarin (but did not know the dose), aspirin and dexamphetamine. He
described the Warfarin capsules as green and yellow. The doctor wrote on the
record that this did not sound like Warfarin. He diagnosed the man with an
apical systolic murmur. (Heart murmurs are relatively common but can indicate
heart disease. It is not clear from the records what grade of murmur he had.)
The doctor recorded that the man had a black eye and bruising to his cheek. He
wrote on the record, “not suicidal” and “says he has worries about other
inmates”.
19. The doctor also made an entry on the man’s continuous clinical record. He
prescribed a week of alcohol detoxification and asked for his heart problems and
the information he had given about his prescriptions for Warfarin and
dexamphetamine to be confirmed with agencies in the community.
20. The man was then taken to the First Night Centre where a second officer
completed the remainder of his first night reception documentation. He said that
he had self-harmed two years previously by attempting to drown himself. He
said that he felt at risk of self-harm and was very concerned about being in
custody. The officer noted that he became agitated when talking about other
prisoners being “after him”. She asked him whether he wanted to be located on
the vulnerable prisoners wing but he declined. She made an entry in his wing
history file:
“Very angry and agitated. Claims he gave evidence against someone years
ago and now everyone from Cornwall is after him. Could not give any names
…”
21. The next day, on 25 June, a third officer wrote on the wing history sheet that the
man appeared to have calmed down but had re-iterated his concerns that he was
at risk from other prisoners.
22. The man completed his day one induction. As part of his induction he was
interviewed by a worker from the CARATS drug and alcohol service. He also
spoke to a woman from Choices Consultancy which is a voluntary organisation
that provides family services in the Devon cluster of prisons. Volunteers speak
to prisoners on first reception to identify any family issues and offer appropriate
support. The third person he spoke to was a Listener. (Listeners are trained by
the Samaritans to provide confidential emotional support to fellow prisoners in
distress. In Exeter Listeners are deployed in the First Night Centre as part of the
prison’s suicide prevention strategy.) The man told the woman from the
consultancy that he had given evidence against a man 14 years previously and
8
other prisoners had already approached him about this. The Listener wrote that
there were “no concerns” raised by his conversation with the man.
23. The man was located in cell B3/1. Staff told the investigator that they allocated
that cell because it was near to the office and gave them more opportunity to
observe him and to see whether he was bothered by other prisoners. The cell
contains a camera which transmits pictures to an office on the ‘centre’. This
office is not routinely occupied except by the Night Orderly Officers and there is
no guarantee that anyone will be looking at the pictures transmitted from the cell.
Staff told the investigator that the man was told that the camera was not
watched. There is a sign on the wall below the camera in the cell that explains
this.
24. Also on 25 June, the substance support nurse manager received a fax from the
man’s community nurse. She had sent the fax late in the afternoon of 24 June,
after the nurse manager had finished his shift. She said that the man was
prescribed 60ml of dexamphetamine daily and he had last collected his
prescription for doses for 20 and 21 June, on 20 June. She said that he had
suffered form endocarditis (an inflammation of the inner layer of the heart) in
December 2008 and had been an inpatient at hospital. However, he had missed
several outpatient appointments. His local doctor prescribed him aspirin and
Ramipril (used to treat hypertension and congestive heart failure) daily and he
had received a 28 day supply of these medicines on 23 June. She added that he
had “stated suicidal intentions” when he was remanded on 24 June.
25. The nurse manager made a record of the information received in the man’s
continuous clinical record. He telephoned the community nurse the same
morning. She told him that the man had episodes of impulsive aggression and
was therefore always visited by two staff. The nurse manager noted the man’s
continuous clinical record, made an entry in the significant events section and put
a red star on the front of the clinical record to indicate that he might be a risk to
staff.
26. At 2.30pm the same day, the man had an appointment with a second prison
doctor. This was made following confirmation from the community nurse that he
had been prescribed dexamphetamine in the community. However, the doctor
wrote on the clinical record that she was unable to prescribe dexamphetamine
because he had not been given a urine test on reception. He was given a urine
test at 4.30pm and then saw the doctor again. He told the doctor that
dexamphetamine made him less paranoid and analytical and he was able to
‘switch off’ better. He thought that he last took a dose of dexamphetamine on 21
June. The doctor wrote that his urine had tested negative for amphetamines and
prescribed a dose building up to his previous level over the next four days. The
doctor also wrote that he told her he was anxious and worried about being on the
main wing. However, he was able to ‘keep to the interview’ and had no psychotic
symptoms.
27. On 28 June, the man completed a wing application form. He asked to see the
Governor as soon as possible. He wrote:
9
“My mental health is in a state, inmates are tormenting me and I think staff are
great, but I still think things will happen to me I do not deserve. Of course I’m
paranoid as I’ve seen what happens in prison. I have a heart condition spent 2
months in hospital recently, 37 years old.”
The form shows that it was passed to the Mental Health In-reach Team and was
received by them on 29 June.
28. Also on 29 June, the man was interviewed by the Offender Management Unit as
part of the Protective Factors Interview/Custody Plan. This document is
designed to ensure that assessments are completed on prisoners within five
days of coming into custody with a view to identifying appropriate positive
supports. The conclusions of the interview are entered on an electronic tracking
system. According to the form completed on him his mental health “anxiety” was
noted but not considered to be a “pathway concern” (meaning it did not warrant
further action by Offender Management). His use of alcohol was considered to
be of concern and it was noted that he had been referred to CARATS.
29. The following morning on 30 June, the man attended a Well Man Assessment
with a Healthcare Assistant (HCA). The HCA wrote that he was “feeling really
low and tearful”. She referred him to the cardiac clinic, the prison doctor and
(again) to CARATS. At interview she was unable to remember him.
30. That afternoon the man was interviewed by a second CARATS worker. She
recorded that he, “seems very stressed about his whole situation”. He told her
he thought he was coping “OK”. He said that landing staff thought he was
paranoid about other prisoners accusing him of being a “grass”. He told her that
the wing staff kept asking him if he was going to hurt himself. He also told her
about his heart complaint. She contacted healthcare and was told that he was
due to be seen in the cardiac clinic shortly. After the interview she asked wing
staff about his concerns about other prisoners and they told her that they had
seen no evidence that he was being bothered.
31. At 4.00pm, shortly after the second CARATS worker spoke to the man, he was
examined by the nurse manager and a nurse in his cell. He had failed to attend
his appointment in the cardiac clinic in healthcare that morning and so they
visited him in his cell. The clinical record shows that wing staff had told the
nurses that they felt that he was “not well”. The nurse manager wrote that the
man presented initially as calm and settled but became more agitated when
discussing his stay in prison. He said the man expressed paranoid thoughts but
was “able to rationalise the process” behind his thoughts. He became more
agitated when explaining that the wing officers did not believe he was at risk from
other prisoners. The nurse manager concluded that the man did not present
paranoid ideation without apparent evidence. He also completed the final reply
section of the application form completed by the man on 28 June. He said the
man had been seen in his cell and a note made in his clinical record.
32. On 3 July, the man attended court and was again remanded to custody. When
he returned to Exeter he said his solicitor had advised him to ask to see a
member of healthcare staff. A Registered Metal Health Nurse (RMN) interviewed
10
him. She wrote in the clinical record that he told her he had received threats to
kill him on the wing and could not return there. He said he was feeling stressed
but had no thoughts of suicide or self-harm. She said he appeared calm when
discussing his problems. At interview she told the investigator that he appeared
relaxed and made good eye contact. She checked his pulse and remembered
that he did not feel clammy. She did not think he had any medical need that
meant he should be located in the healthcare centre. She discussed his situation
with discipline staff afterwards and thought that they located him in a camera cell
on B wing. In fact he returned to cell B3/1 where he had been located since
arriving at Exeter.
33. During the afternoon of the next day, Saturday 4 July, the third officer and a
Senior Officer (SO) became especially concerned about the man’s mental health.
The officer told the investigator that he remembered the man from previous
sentences he had served at Exeter. He said that his behaviour was very
different to how he remembered him. The man seemed paranoid that other
prisoners were “out to get him” and obsessed with the need to get hold of a
newspaper clipping that proved he was not a “grass”. The officer said that the
man had been much more distressed since returning from court on 3 July and he
was especially concerned by his behaviour on 4 July. The SO said that the man
could not tell him who wanted to harm him or whether they had approached him.
He told the SO that he did not feel safe and wanted to be transferred to the
vulnerable prisoners wing. However he changed his mind when he realised that
even as a vulnerable prisoner he would not be moved from B wing. (Because of
overcrowding and the number of vulnerable prisoners, the vulnerable prisoner
wing was full and the overspill was being located on B wing.)
34. The third officer discussed the man’s behaviour with the SO and they decided to
ask a third prison doctor to come to the wing to examine him. By coincidence,
before he went to see him, the doctor asked the RMN where he could find the
man’s clinical record and she was able to tell him about her interview with him
the previous day.
35. The third prison doctor talked to the man in his cell at 3.30pm. He wrote in the
clinical record that he did not display any signs of acute psychosis. He had some
paranoid thoughts but these were grounded in rational feelings. The doctor said
the man had no thought disturbance but asked to speak to him again the
following week so he could decide whether a referral to the psychiatrist was
appropriate. The doctor spoke briefly to the third officer to tell him that he felt the
man was suitable for normal location and did not require any intervention from
healthcare.
36. At approximately 1.50pm the following afternoon the third officer asked the man if
he wanted to come out of his cell for the exercise period. He said he did not and
the door was closed. At approximately 3.44pm, the officer began unlocking the
cells on B wing for prisoners to collect their teatime meal. When he looked
through the observation flap of the man’s cell he saw him suspended from the
light switch with his feet off the floor.
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THE PRISON’S RESPONSE TO DISCOVERING THE MAN HANGING
37. The incident log shows that the SO made an emergency call from B wing at
3.44pm. He said the emergency was Code Blue which means someone is
having difficulty breathing. The call was acknowledged immediately by a PO (the
orderly officer) and the duty governor. At 3.46pm an ambulance was called and
it arrived at the prison gate at 3.52pm. By 3.54pm the ambulance was in B wing
yard and the paramedics were in the man’s cell.
38. When he saw the man hanging, the third officer shouted for assistance and
entered the cell. He supported the man’s weight and a fourth officer cut through
the shoelace the man had used as a ligature using his cut down tool. The
officers laid him on the cell floor and the fourth officer used his knife to remove
the rest of the ligature from the man’s neck. The fourth officer said that the
man’s body was lifeless and he was blue in colour. He said he could not detect a
pulse. A second SO had arrived in the cell by this time and he started
emergency breaths while the fourth officer started chest compressions. The
officer thought that he had gone through about ten to 15 cycles of compressions
when the nurse entered the cell and took over from him.
39. The nurse said that he was working in the C wing treatment hatch when he heard
a Code Blue call to his call sign on the radio. He immediately closed the hatch
and used his radio to verify the exact location of the emergency. He said he
realised that the incident must be serious because the prisoners were being
asked to return to their cells. The nurse arrived at the man’s cell and felt his
brachial artery for a pulse. (The brachial artery is in the arm above the elbow
joint. The nurse felt there for a pulse because there had been trauma to his
neck.) The nurse could not feel a pulse. He then took over chest compressions
from the fourth officer while the second SO continued emergency breaths
through a mask. The nurse said they worked in a cycle of 30 compressions to
two breaths at a rate of 100 compressions per minute.
40. A second nurse said she was working in A wing treatment hatch when she heard
a Code Blue emergency call on her radio. Shortly afterwards she heard a call for
A wing prisoners to be returned to their cells and realised that there must be a
major incident. The Primary Care healthcare manager told her that he would
collect the emergency bag and so she collected the defibrillator from the centre
and went to B wing. On her way she saw the first nurse running up the spiral
staircase ahead of her. The healthcare manager arrived at the man’s cell almost
at the same time and oxygen was given to the man using an ambu-bag. The
second SO then attached the defibrillator to him and the machine advised to
continue with CPR. (A defibrillator will only advise a shock if a heart rhythm can
be detected.) The nurse and the SO continued CPR until the paramedics arrived
and took over from the SO. After several more cycles of CPR a pulse was
registered and the nurse stopped compressions. Oxygen was continued and the
man was taken to hospital by ambulance.
41. The Principal Officer (PO) was the orderly officer on Sunday 5 July. He said that
he was on the centre with two SOs when he heard the Code Blue on the radio.
He said he immediately sent both of them to B wing. He used the tannoy system
12
to request that all prisoners be returned to their cells. He then went to B wing
where he found staff giving the man emergency aid. The nurse told him that the
man was not breathing so he used his radio to order a 999 call for an ambulance.
He left the cell when the paramedics arrived and made arrangements for two
officers to escort the man to the hospital. He then checked that the two officers
were alright before returning to the centre and ordering staff on A and C wings to
resume unlocking prisoners for their teatime meal.
42. Although the man was alive, his condition was critical and so the prison’s death
in custody contingency plans were followed. All the relevant people in the
National Offender Management Service (NOMS) were contacted.
43. Once prisoners on A and C wings had eaten their meal and been given their
medication, staff were sent to B wing to help give those prisoners their meals and
medication. A chaplain visited two prisoners who were in the cell opposite the
man and who had witnessed him hanging when the third officer opened the cell.
A count of all the prisoners was agreed and the duty governor supervised a hot
debrief for staff who had been involved in the discovery and resuscitation of the
man. All prisoners on open ACCT forms (the document used by NOMS to
monitor prisoners thought to be at risk of suicide and self harm) were checked
later the same evening.
44. Contact with the man’s next of kin was discussed by the duty governor and the
chaplain. As he was still alive it was decided to ask the family’s local police to
visit them as soon as possible. The police eventually contacted his mother in the
late evening and she and his two sisters travelled to the hospital as soon as
possible. A second chaplain visited the hospital daily and spent time with the
man’s family. The Governor also went to the hospital on two occasions but
unfortunately missed the family on both occasions.
45. The second chaplain was with the man’s mother and sisters when he died. On
the following Sunday he incorporated a memorial service for him into the regular
service in the prison chapel.
13
WHAT OTHER PRISONERS SAID
46. A prisoner said he had occupied the cell next door to the man until 4 July. He
thought he was the prisoner who had been closest to him during his time in
Exeter. He said that he had said hello to him when he arrived on the wing. He
saw other prisoners giving the man “bad looks” and thought that this was
because someone had spread a rumour that he was a “grass”. The prisoner said
he had spoken to the man about these rumours and said that he did not believe
they were true. He said the man had spent some time and energy arranging for
his ex-wife to send a newspaper clipping into the prison that he thought proved
that he was not a “grass”. He said that the man had asked him to show the
clipping to other prisoners but had actually done so himself.
47. The prisoner said he and the man used to sit in his cell and share cigarettes. He
said the man showed him pictures of his children. He said he thought the man
was upset about his poor relationship with his “missus” as this meant he had
trouble seeing his children. The prisoner said that the man obviously thought the
world of his children.
48. The prisoner described the man as a “nice fellow” and said they got on very well.
He knew he was “down” but did not know what about, apart from the gossip and
not seeing his children. He said he thought the man felt he was at risk of being
“jumped by kids from Redruth” but did not think he was at risk of self-harm. He
said the man never talked to him about “topping himself” and his death had come
as a great shock to him.
49. The prisoner said there was a camera in his cell on B wing. He said there was a
notice on the wall below it that made it clear that the camera was not being
watched all the time. He said staff had also explained this to him when he was in
that cell. He did not remember the man talking about the camera in his own cell.
The prisoner said he was very sorry that the man had killed himself and said he
would like his condolences to be passed on to the family.
50. A second prisoner said it was his first time in prison and he had only been in the
prison some two weeks before the man attempted to hang himself. He said that
as far as he could remember he had not seen or spoken to him on the wing. He
was not aware of any rumours about him or bad feeling towards him. The
prisoner said he occupied the cell opposite the man on B3 landing. He shared
this cell with another prisoner.
51. On 5 July 2009, the second prisoner said an officer unlocked his door and then
unlocked the man’s cell. He heard the officer call for assistance. He looked
across and saw the man hanging from the light fitting. The prisoner said that
very quickly his own door was shut and the observation flap was closed. He said
he could still see out of his cell through a gap in the door and he saw officers
working on the man giving him CPR.
52. The second prisoner said that “the female chaplain” had come to see him later
that day and that B wing officers asked him regularly “for several days after” if he
was alright. He said he felt he had been adequately supported. He could not
14
remember how other prisoners were told about the man’s death but said that the
wing was kept up to date with his condition in hospital.
53. A third prisoner said he had been in the cell opposite the man on B3 landing for
about a week. He said he had spoken to him and he had seemed “alright but
sometimes a bit distant”. He said he thought the man had seemed a bit “up and
down” in his moods. The prisoner said he had heard a rumour about the man
but he had not seen any other prisoners picking on him or arguing with him. He
thought that he had seemed “a bit paranoid”. He saw him once in his cell sitting
on the bed rolling a cigarette and looking miserable. The prisoner said he had
thought the man might not have been alright on 5 July because he said he had
not wanted any dinner or exercise. He also thought there was something “up
with him” because he was in a single cell with a camera and close to the wing
office. He spoke to him during the morning of 5 July about his canteen sheet and
described this as a “normal interaction”.
54. On 5 July, the third prisoner said he remembered the third officer unlocking his
cell and then going over to the man’s cell. He said the officer looked through the
man’s observation flap, shouted “he’s topped himself”, used his radio to call a
Code Blue and then unlocked his cell and went inside. The prisoner said he saw
the man hanging from the light in his cell. He said he thought he was “gone”. He
said he saw his bin lying on its side and rubbish over the floor of the cell. He
said he saw the officer support the man and another officer cut him down. He
saw the officer start to work on the man’s chest. When other officers arrived on
the wing he was locked in his cell. He said he thought that the officers had “done
a good job” trying to revive the man.
55. The third prisoner said that the staff at Exeter had been “brilliant”. Two nurses
and a vicar had seen him the same day and the wing officers still asked him if he
was alright. He said he had seen a chaplain again only two days before the
investigator interviewed him.
15
ISSUES CONSIDERED DURING THE INVESTIGATION
The management of the man’s risk
56. A number of documents in the man’s prison record indicate that he was at risk of
self-harm or suicide. The PER form completed by the police for transfer from the
police station to the magistrates court informs us that he said he had attempted
to kill himself two years previously by drowning. As far as I have been able to
establish, this is the only reference to an attempt of self-harm or suicide in his
history. During his previous sentences at Exeter he had no history of such
behaviour and had not been identified as at risk in prison.
57. Apparently the man spoke to someone at court on 24 June and told her he felt
suicidal. I have not seen a PER for his journey from court to prison on 24 June
but this was referred to by the community nurse in her fax of 24 June.
Unfortunately the member of staff in question went on long term sick leave
shortly afterwards and the investigator did not speak directly to her. The
investigator did speak to the community nurse who reported that her colleague
had said that the man was anxious about going to prison. She had known the
man for several years but had no knowledge of any attempt by him to drown
himself. She said that he had a history of unpredictable behaviour and mood
swings but not of self-harm or suicidal thoughts.
58. The man was consistent in his responses to the question of whether he felt like
harming himself. He told the nurse and the first prison doctor at his reception
healthscreen that he was angry, stressed and anxious about being in prison but
denied he was suicidal. The first night paperwork completed by the second
officer indicates that he was feeling suicidal and he told her that he had tried to
drown himself two years previously. However, the discussion was
overwhelmingly about his anxiety about other prisoners and shortly afterwards he
raised no concerns with either the volunteer from Choices Consultancy or the
Listener in Reception. He was reviewed during the remainder of his time in
Exeter by two other doctors, three other nurses and a healthcare assistant. He
was also interviewed by a CARATS worker and trained ACCT assessor. She in
effect took him through a basic ACCT assessment in this interview. She also
spoke to wing staff and healthcare staff immediately afterwards. This is good
practice. On each occasion he was spoken to, he denied feeling suicidal. I am
therefore satisfied that his actions on 5 July could not have been foreseen or
prevented.
The CARATs worker follow up of the man’s concerns (with wing staff
and healthcare staff) is good practice.
59. At every opportunity, whether talking to staff or prisoners, the man said that he
was anxious about being in prison because he felt other prisoners were ”out to
get him”. He put this down to the fact that he had appeared as a witness in the
trial of a man from his community some years previously. At no point did he
name any of the prisoners who he thought were after him nor did he mention any
specific incidents when he had been threatened, harassed or bullied. Neither the
prisoner who spent most time with him in Exeter nor wing staff ever witnessed
16
any such incidents. He might have had good reason to be concerned for his
safety but I have seen no evidence to suggest that any other prisoners posed a
threat to him.
60. There is evidence that staff took the man’s anxieties seriously. They put him in a
cell that was easily observed from the wing office and made efforts to check if
anyone approached his cell. Despite the issues of overcrowding at Exeter and
the pressure on places on B wing, he was kept in the same cell throughout his
time at Exeter.
61. When he returned from court on 3 July, the man discussed accepting vulnerable
prisoner status. After discussion with B wing staff it was thought that it was
better to keep him close to the staff who knew him. In his application form of 28
June, he acknowledged that staff were “great”. He told his CARATS caseworker
on 30 June that wing staff asked him regularly if he was going to hurt himself. I
am satisfied that staff exercised their duty of care to him and that it was
reasonable to assess that he was not at risk of suicide.
62. There appears to be some confusion among healthcare staff about the use of the
in-cell cameras on B wing. Wing staff are clear that, although his cell contained
a camera, he was not placed in that cell for that reason but because of its
proximity to the wing office. The first prisoner, who occupied the cell next to him,
which also contained a camera, told the investigator that it had been explained to
him that the camera was not watched and there was a sign below it that made
this clear.
63. I have seen no evidence that the man thought that he was being monitored for
his own safety. (He did tell the second nurse and the nurse manager on 30 June
that he thought he was being watched through his toilet screen but was vague
about who was watching him and whether he was being watched all the time.)
The RMN appears to have been left with the impression that he was being
monitored in a camera cell after she spoke to staff in reception when he returned
from court on 3 July. The clinical reviewer was also under the impression after
interviewing the doctors that the man was being monitored in a camera cell. The
SO told the investigator that he had had to explain to healthcare staff on past
occasions that the cameras were not used to watch prisoners thought to be at
risk.
64. In order to make informed decisions about the safety of prisoners’ healthcare
staff need to be aware that the cameras in the cells on B wing are not routinely
used to monitor prisoners.
I recommend that the Head of Healthcare issues a notice to all
healthcare staff informing them that the cameras on B wing are not
routinely used for monitoring prisoners and the cells are not used as
‘camera cells’ or specifically for prisoners thought to be at risk of self-
harm or suicide.
This recommendation was accepted by NOMS at draft report stage.
17
The clinical care offered to the man
65. The clinical reviewer’s review appears in full at annex one of this report. The
doctor praised the admission process at Exeter and the fact that his exact
medication was confirmed before he was prescribed any drugs. He also
concluded that the man was reviewed a number of times by healthcare staff in
Exeter and therefore there was ample opportunity for him to share his feelings
with staff. He makes two recommendations which I endorse.
66. I should like to add that I was impressed by the number of times the man was
reviewed by healthcare staff during a relatively short period. The quality of the
entries in the clinical record made by the nursing staff was also high. In
particular I consider it was good practice for the nurse manager to telephone the
community nurse after receiving her fax. Although the fax contained useful
information, the telephone call elicited even more – including the fact that the
man was subject to impulsive outbursts of aggression and was always visited by
two members of staff together. Although he did not present a threat to staff in
Exeter it is nevertheless important that staff are aware of this type of behaviour,
not only for their own safety but also for that of the prisoners in their care, some
of whom might be expected to share his cell.
The telephone call from the nurse manager to the community nurse was
good practice.
The response to finding the man hanging
67. I am satisfied that staff responded appropriately to the discovery that the man
had attempted to kill himself on 5 July. The third and fourth officers acted
promptly to remove the ligature and place him on the floor. The fourth officer
Winfield, the second SO Cole and the nurse provided emergency aid in
accordance with the latest guidance from the Resuscitation Council. Chest
compressions and breaths must be done properly to stand any realistic chance
of reviving a person whose heart has stopped. The fact that the man’s heart was
restarted is testimony to the high quality of emergency aid given by Exeter staff.
Unfortunately it appears his brain had been without oxygen for too long for him to
have survived.
68. All the emergency equipment was in working order and was taken to the man’s
cell in a timely manner. Paramedics were at his cell only ten minutes after he
was discovered. I am satisfied that the prison staff did all that was possible to
save his life.
69. I consider that the management of the emergency on 5 July by the duty governor
and the PO was efficient and timely. Staff reported that it was very difficult to be
expected to complete their shifts before being allowed home. I have great
sympathy with them. Unfortunately, when emergencies of this nature occur at
weekends or at night, current staffing levels do not allow for cover to be provided.
Neither is it within my gift to remedy this situation. It is therefore very important
that staff are properly supported in the aftermath of these traumatic events. I am
pleased that all the discipline staff told the investigator that they had felt
18
appropriately cared for by colleagues, the chaplaincy and the care team. All the
staff found the hot debrief led by the duty governor very helpful.
70. I am disappointed however that this level of support does not appear to have
been extended to all the healthcare staff who tried to save the man’s life. One
nurse said she had spoken to the first SO and the PO on the day but had not
been approached by the care team or by managers then or in the days following.
Unfortunately, I have heard the same experience reported in other cases
investigated by the Ombudsman.
I recommend that, in the light of the feedback received from healthcare
staff during this investigation, the Governor and the Head of Healthcare
ensure that systems are in place to offer appropriate support to all staff
involved in fatal incidents.
This recommendation was accepted by NOMS at draft report stage.
71. I am also pleased that the prisoners on B wing interviewed by the investigator
told her that they had been kept informed of the man’s condition and had
regularly been asked about their wellbeing. I note too the active role of the
chaplains in offering support to staff and prisoners after the sad events of 5 July.
72. The exception was the prisoner who probably spent most time in the man’s
company in Exeter. He was moved to a different wing the day before the man
attempted to kill himself. When the investigator interviewed him he told her he
had been unaware of his death until he received her letter inviting him for
interview.
73. The prisoner was on an open ACCT form for reasons unrelated to the man’s
death. He was understandably upset by the manner he heard about his death. I
understand that the acquaintance between the man and the prisoner was recent
and of short duration. I also understand that in a busy and overcrowded local
prison where there is huge pressure on spaces in the first night and induction
centre, it is impossible for staff to keep track of every prisoner friendship.
However, 12 days is long enough on one wing for prisoners to form bonds. Also
the man was a local man in a local prison where he had served sentences before
and therefore it is likely that he may have had other friends of longer standing
elsewhere in the establishment. It is important that news of a death in custody is
disseminated throughout the wider prison.
I recommend that the death in custody contingency plan at Exeter is
amended to ensure that the Governor’s notice to prisoners informing
them of a death is put up on every wing.
This recommendation was accepted by NOMS at draft report stage.
74. In previous reports into two apparently self-inflicted deaths at Exeter in 2007 the
Ombudsman made three recommendations which are relevant to the
circumstances of the man’s death. The first was that the healthcare manager
and PCT initiate a procedure for obtaining a prisoner’s consent to the disclosure
19
of confidential medical information about them, secondly a colour code system
was to be introduced for use in emergency situations and finally that a hot debrief
should always take place after a death. I am very pleased to see that all of
these measures were in place in this case.
Family liaison and issues raised by the man’s family
75. The man’s mother told the Ombudsman’s family liaison officer that she had a
number of concerns about the treatment her son had received in the community.
She said that she had been extremely worried about her son’s mental health in
the period leading up to his remand in custody. She had tried to persuade
community mental health staff to have him compulsorily admitted to hospital
under the Mental Health Act for his own safety. She said that they had told her
that her son would be safe in prison. They said that he would be put on suicide
watch and checked every 15 minutes. Their actions are outside my remit and I
have not investigated these comments. The Coroner may wish to address the
man’s mother’s concern about those actions at the inquest.
76. The man’s mother told the family liaison officer that she had great difficulty in
contacting the prison’s family liaison officer. She was disappointed that no one
from the prison attended the funeral. She said that the chaplain had been a
great comfort to the family while they were with her son in hospital and when he
died. The investigator spoke to the chaplain and he expressed regret that he
could not attend his funeral. He said he had telephoned the man’s mother to
apologise and to ask about the service. Another chaplain commented to the
investigator that, after being very involved with the emergency on 5 July, she had
felt ”out of the loop” in the following week. She thought that a lack of direction
and central point of contact had contributed to, amongst other things, the fact
that no staff had attended his funeral.
77. The lack of a central point of contact was an issue that other staff expressed to
the investigator. The duty governor, who was in charge on 5 July, went on
annual leave the day afterwards and it does not appear to have been made clear
to staff who would assume responsibility for taking overall control in his absence.
I expect too that this was felt more keenly because it was some days before the
man died. I draw this to the attention of the Governor for learning purposes.
78. When the man died the prison properly agreed to meet the costs of his funeral.
Unfortunately, the bill was not paid to the funeral directors until 23 November –
almost five months after he died. Both the man’s mother and the Ombudsman’s
family liaison officer found it extremely difficult to contact the prison liaison
officer. The situation was only resolved when another of my colleagues visited
the prison on a different matter.
79. This delay is unacceptable and can only have added to the man’s mother’s
distress. I understand that the prison’s family liaison officer had a family
bereavement. I am sympathetic to his personal circumstances but consider that
if he was unable to fulfil his responsibilities he should have been replaced. This
was an issue for his management. The role of family liaison officer is hugely
20
important and there must be measures in place to make sure that it is properly
fulfilled.
I recommend that the Governor of Exeter satisfies himself that there are
effective management structures in place to ensure that the prison
family liaison officers are properly fulfilling their role.
This recommendation was accepted by NOMS at draft report stage.
21
CONCLUSION
80. I am satisfied that the care received by the man in Exeter was of a high standard.
I do not consider that his death comes into the category of so called preventable
deaths where a risk was not identified. All the decisions made about his care and
the nature of his risk were reasonable. The emergency aid given to him was
exemplary and the incident management on the day of 5 July was highly
organised and efficient. There is evidence that most wing staff and most of the
key prisoners received proper support.
81. Unfortunately the family liaison provided to the man’s family did not reach the
heights of the care given to him. I am also disappointed to hear a familiar
complaint from healthcare staff that the care offered to them was not consistent
with that offered to discipline staff. The management of healthcare in prisons is
no longer the direct responsibility of the Governor and therefore it is important
that further divisions between discipline and healthcare staff do not occur. The
clinical review at annex one also references communication between discipline
and healthcare staff.
82. In common with other local prisons Exeter prison is struggling with overcrowding.
There are more vulnerable prisoners than can live on the designated wing (D
wing) and the overspill means that places on B wing (designated as first night and
induction wing) are at a premium. Staff expressed their concern to the
investigator that they could not properly look after new receptions as there was
little chance of retaining them on B wing. This is not a situation that I (or anyone
at Exeter) can remedy but, in writing these reports, I am constantly reminded that
overcrowding in prisons increases the stresses and demands on staff and has
implications for the safety of prisoners.
22
RECOMMENDATIONS
1. I recommend that the Head of Healthcare issues a notice to all healthcare
staff informing them that the cameras on B wing are not routinely used for
monitoring prisoners and the cells are not used as ‘camera cells’ or
specifically for prisoners thought to be at risk of self-harm or suicide.
2. I recommend that there should be an improvement in the legibility of the
doctor’s entries in the clinical record and that all entries should be signed and
the name of the doctor printed under the signature.
3. I recommend that, in the light of the feedback received from healthcare staff
during this investigation, the Governor and the Head of Healthcare ensure
that systems are in place to offer appropriate support to all staff involved in
fatal incidents.
4. I recommend that the death in custody contingency plan at Exeter is amended
to ensure that the Governor’s notice to prisoners informing them of a death is
put up on every wing.
5. I recommend that the Governor of Exeter satisfies himself that there are
proper management structures in place to ensure that the prison family liaison
officers are properly fulfilling their role.
From the clinical review:
1. The use of Camera surveillance in the prison cells. There seems to have been
a breakdown in communications between the Prison Staff and the Health Care Staff
regarding the use of the cameras in camera cells. The medical staff seemed to think
that the cameras should be monitored regularly but in fact they were not monitored
at all and there are signs in the cells explaining this to prisoners. I recommend the
two services should start regular liaison meetings with the aim of improving working
relationships between the two sides.
2. Routine health checks for prisoners entering custody. These were all
performed at the correct time but some of the entries were illegible and the
signatures were not recognisable. I recommend that there should be an
improvement in the quality of the entries in the IMR and that all entries should be
signed and the name of the clinician printed under the signature.
Good practice:
The second CARATS worker follow up of the man’s concerns (with wing staff and
healthcare staff) was good practice.
The telephone call from the nurse manager to the community nurse was good
practice.
23