Individual at Aylesbury

Investigation into the circumstances surrounding the
death of a man at HMYOI Aylesbury
In December 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
1
This is a report following the death of a man in December 2008 at Her Majesty’s
Young Offender Institution (HMYOI) Aylesbury. He was found hanging in his cell
in the early hours during a routine check. Despite staff’s efforts to resuscitate him,
he was pronounced dead by the paramedics 20 minutes after he was found. He
had been in custody for just six months and had already been moved between four
different establishments, with little more than a week at Aylesbury. The man was
18 years old.
I pass on my sincere condolences to the man’s friends and family for their loss. I
trust that this report addresses the questions that they have about his care in
prison. I must apologise for the delay in issuing the draft and final reports and the
additional distress this has caused.
The investigation was carried out by my colleague. I would like to thank the local
Primary Care Trust (PCT), and the appointed clinical reviewer, for their
contribution to the investigation process. The clinical review is the first annex to
this report. I am also grateful to the Governor of Aylesbury and the investigation
liaison officer for their help throughout the investigation.
The man was only 17 years old when he committed the offence that attracted
much media coverage. He had been transferred from a prison for those under 18
to the young offender institution for 18 to 21 year olds less than a month before his
death. During those few weeks, he was apparently the victim of bullying.
As well, the prescription for the man’s mental health medication had expired. He
arrived at Aylesbury without a prescription and received no further medication
before he died. On the day before his death he told his family he was worried that
other young offenders had found out the nature of his offence and that he would
become the target of bullying. Suicide prevention measures were started the day
he arrived at the YOI, but was closed the next day.
I have examined the procedures for transferring medication, investigating bullying
and the assessment of risk in Woodhill and Aylesbury. I make seven
recommendations.
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
Deputy Prisons and Probation Ombudsman June 2010
2
CONTENTS
Summary
The Investigation Process
HMYOI Aylesbury
Key Events
Issues
Conclusion
Recommendations
3
SUMMARY
At the time of his death the man was 18 years old and serving a seven and half
year sentence at HMYOI Aylesbury. He was first sent to HMYOI Feltham on 6
June 2008 when he was remanded into custody. Both Luton Youth Offending
Team and the prisoner custody officer sent suicide and self harm and vulnerability
warnings to Feltham. During his first reception healthscreen and reception
assessment, he told staff he was not at risk of harming himself. The following day,
however, he was identified as being particularly low in mood and Assessment
Care in Custody and Teamwork (ACCT) self harm risk management procedures
were initiated. They were closed following a full assessment the next day, on 8
June.
During the rest of June and July, the man settled at Feltham. He earned himself
enhanced status under the Incentives and Earned Privileges Scheme. (The
Incentives and Earned Privilege (IEP) scheme is designed to encourage and
reward positive behaviour. The scheme has three levels: standard, basic and
enhanced.) On 18 August, he appeared at Crown Court and pleaded guilty. He
was remanded following the judge’s request for psychiatric reports before
sentencing.
Following a further court appearance, the man was transferred to HMYOI Glen
Parva on 8 September. He initially continued to progress well. However, on 10
November, he told staff he felt depressed. At the suggestion of a mental health
worker, he was assessed on 17 November by a consultant psychiatrist who
prescribed an antidepressant. He continued treatment with a mental health worker
and responded well. On 3 December, he was assessed by a different psychiatrist
for the court report, who concluded that he was not mentally ill.
The man was sentenced at Crown Court on 11 December. After his court
appearance he was transferred to HMP Woodhill with his friend. Healthcare staff
at Woodhill noted that he was prescribed an antidepressant. Whilst at Woodhill
both he and his friend were subject to bullying and intimidation over their offence.
After some wing moves, it was agreed to transfer them both to HMYOI Aylesbury
on 18 December.
Neither his drug chart, the ACCT document from Woodhill, nor a supply of his
medication, were transferred with the man. Healthcare staff on reception started
suicide prevention measures for a second time. They were closed the following
day. He was in a positive mood when he was assessed by the prison doctor on 22
December. The doctor noticed his prescription, but agreed to his request to stop
taking his antidepressant. He reported his fears to staff that other prisoners had
found out about his offence, although staff recorded that he mixed well on the
induction unit for the rest of the week.
During a routine observation check in the early hours of 26 December 2008, an
officer found the man hanging by a ligature in his cell. Officers and healthcare
staff responded quickly to his emergency call for assistance. Despite efforts to
resuscitate him, his death was confirmed by paramedics. A doctor pronounced
that he had died at 4.55am.
4
THE INVESTIGATION PROCESS
1. I appointed a senior investigator to conduct the investigation into the
circumstances surrounding the man’s death. Another of my colleagues visited
Aylesbury on 4 January to collect the paperwork and meet the man’s friend to
explain the investigation process. The second investigator also met a
representative from the Prison Officers’ Association and Independent
Monitoring Board (IMB).
2. Notices were sent to the prison to invite prisoners and staff to contact the
investigator with any information that thought was relevant to the
investigation. There was no response to these notices.
3. The prison liaison officer organised for the man’s prison records to be copied
in time for the investigator’s visit on 16 January. As well as looking round the
prison and reviewing his files, she introduced herself to the Governor. That
afternoon, she met the Clinical Governance Manager from the local PCT.
4. Accompanied by a colleague, the investigator conducted interviews with staff
and prisoners at Aylesbury on 9, 10 and 11 February. She also interviewed
the man’s close friend at HMP Wellingborough as part of the investigation
process. The clinical reviewer was not present at these interviews, but he
was sent copies of the interview transcripts for his consideration as part of the
clinical review process. He accompanied the investigator to Aylesbury on 1
July to carry out some follow-up interviews. I am grateful to the local PCT for
appointing the clinical reviewer and commend his clinical review, which is the
first annex of this report.
5. The investigator wrote to HMP Woodhill requesting copies of the prescription
charts and the Assessment, Care in Custody and Teamwork document
recorded to have been opened and closed at Woodhill. The ACCT document
was sent, but the prescription chart was not. She also spoke to the Head of
Healthcare at Glen Parva during the course of the investigation.
6. The Ombudsman’s senior family liaison officer arranged to meet the man’s
mother, with the investigator. The man’s mother explained that her main
concern was that he was not taking his medication at the time that he died.
She was worried that he had been moved to Woodhill, despite telling her that
he was happy at Glen Parva and needed to return there for the continuation of
his medical care. She also expressed her concern about the content and
quality of the entries made in his clinical record.
7. The man’s mother and close friend both raised concerns about the man being
bullied at Woodhill and Aylesbury. She told my investigator that he had
spoken to his grandmother on the afternoon before his death seemed fine, so
she was worried that he had been bullied later that day. She was also
surprised by the media attention that his death received and felt that the
prison could have done more to prepare her. I am grateful to the family for
their valuable contribution to my investigation. I trust that the concerns they
raised have been addressed in this report.
5
8. The family liaison officer also wrote to the man’s sister at HMP Peterborough
to offer her the opportunity to contribute to the investigation process.
6
HMYOI AYLESBURY
9. HMYOI Aylesbury is a young offender institution holding long term sentenced
young adult males between 18 and 21 years of age serving from two years to
life imprisonment. Up to 444 young adult prisoners live on eight wings in
accommodation which is certified to hold 437 prisoners. Four additional
wings, built in 1902 and 1997, were added to the original Victorian wings. ‘D’
Wing is the induction unit, holding up to 55 prisoners.
10. There have been no self-inflicted deaths at Aylesbury since the Ombudsman
took over responsibility for undertaking death in custody investigations in
2004. The last self-inflicted death occurred in 2003. Following this death,
staff introduced routine observations of young adults at two hour intervals
throughout the night, a practice that is still in place today. In fact, it was
during such a check that the man was found in the early hours.
Her Majesty’s Chief Inspector of Prisons (HMCIP)
11. Her Majesty’s Chief Inspector of Prisons carried out an unannounced
inspection in June 2005. The inspectors found “impressive arrangements to
prevent suicide and self harm”. The team also noted that “there had also
been significant progress in the management of bullying”.
12. The Chief Inspector has since carried out a full announced inspection after the
man’s death in March 2009. The Chief Inspector found that ACCT
procedures were “satisfactory” and found “clear evidence of a multidisciplinary
approach to the care of those at risk”, a matter which I will examine further
later in this report. The inspection team were concerned about the number of
people attending case reviews, or providing a written contribution and the
quality of ACCT entries. The team also noted that there were no Listeners on
the induction unit, where the man was located. (A Listener is a prisoner who
has been trained by the Samaritans to support prisoners through periods of
crisis.)
13. As part of their inspection, the team examined violence reduction procedures
and was concerned at an apparent “under-reporting” of violent incidents,
although found that they were “generally good”. The inspectors observed that
young adults were shouting out of their windows, both during the day and at
night, but prisoners mostly felt that the prison was quiet enough to sleep in at
night.
14. Each prison in England and Wales has an Independent Monitoring Board
responsible for monitoring day-to-day life in the prison and to ensure that
proper standards of care and decency are maintained. In his annual report,
the Chair of the IMB found that the YOI “takes a strong and well managed
approach to Safer Custody” and the policy for violence reduction was “long
standing and effective”.
7
Assessment, Care in Custody and Teamwork (ACCT)
15. ACCT is a set of procedures designed to reduce incidences of self inflicted
death and self harm. It provides prisoner centred assessment and care
planning, offering personalised care and support before, during and after
crisis.
Youth Offending Team (YOT)
16. A Youth Offending Team is run by every local authority and combines
representatives from all of the local services required to care for young people
involved in the criminal justice system.
HMYOI Feltham, HMYOI Glen Parva, HMPYOI Woodhill
17. HMPYOI Feltham takes both offenders from 15 to 18 years deemed
unsuitable for secure local authority accommodation, and also offenders
between the ages of 18 to 21 years sent into custody by the adult courts. Due
to the population pressure in the London area, young adults who are not
scheduled to have a court appearance in London within three months are
often moved to other establishments.
18. HMYOI Glen Parva holds both remand and sentenced young people and
young adults. Like Feltham, it is a split site prison, with one part dedicated to
young people under 18 and the other to prisoners between 18 and 21 years of
age. Glen Parva is one of three prisons to which Feltham routinely transfers
prisoners.
19. HMPYOI Woodhill is a local prison serving both Crown and Magistrates
Courts. It takes sentenced prisoners with a view to allocation to other
establishments. These include a small number of young adult offenders
between 18 and 21 years of age.
8
KEY EVENTS
HMYOI Feltham
20. The man was remanded to HMYOI Feltham following a court appearance on
6 June 2008. A suicide and self harm warning form was completed by a
prisoner custody officer (PCO), and sent with him from court to Feltham. It
identified that the man was depressed, had not been in prison before and that
he “states that he will harm himself if he is beaten up while in custody”. It
recorded he had a history of self harm by an overdose in the past one to five
years. Similarly, the Youth Justice Board sent a ‘placement alert form’
indicating “vulnerability” with its placement confirmation form. The alert form
specified mental health concerns, a history of abuse or trauma, and his
eligibility for support under leaving care legislation.
21. According to the reception nurse, who carried out his first reception
healthscreen, the man was “very tearful, frightened”. (A first reception
healthscreen is an interview by healthcare staff which takes place when a
prisoner arrives at the prison. It should determine any physical or mental
health conditions that require treatment, and any risk that the prisoner may
pose of harming himself or attempting suicide.) During the healthscreen, he
told the nurse that he had attempted suicide by overdose on New Year’s Eve
2007. Following his overdose, he explained that he received psychiatric
treatment as an outpatient at hospital. He also told the nurse that his uncle
had died in the previous year.
22. When asked whether he was thinking of harming himself at the time, the man
replied, “I won’t do anything, I don’t want to upset my mum”. The reception
nurse did not consider him at risk of harming himself and therefore did not
start ACCT procedures. As the man had received mental health treatment in
the community and had previously self harmed, he was referred to the mental
health inreach team.
23. Any young person under the age of 18 has to undergo an initial custody
reception assessment (T1:V) which focuses on the assessment of their
vulnerability and risk. When asked whether he had any concerns about being
in prison, the man told an officer that he was worried about “trouble with his
peers”. The officer reassured him that staff would be around at all times. The
officer went on to note that the man’s “first night nervousness [was] to be
expected”. The officer did not think that the man was at risk of harming
himself so he did not start an ACCT document either.
24. A member of the mental health inreach team saw the man that evening at
7.40pm following the reception nurse’s request. During the conversation, he
again discussed his anxiety about other young people and the nurse
“reassured him he won’t be alone”. After their conversation, the nurse found
“there appeared to be no obvious mental health issues at this time”.
25. The next evening, the officer noticed that the man was “quite tearful” when he
was collecting his evening meal. The man said that he was feeling “very low
9
and missing his mum”. The officer arranged for him to use the unit telephone
to call his mother and for the inreach team to visit him the next morning. After
her telephone call with him, his mother told staff that she was “very worried
about him”. A Senior Officer (SO) raised a Concern and Keep Safe form, the
first stage of the ACCT process. She recorded that he was “very upset at
being in prison” and he “has stated he has had enough of life”. She
suggested that he would “need watching during the settling in period at
Feltham”.
26. During the ACCT assessment on 8 June, the man was “tearful from time to
time” but assured staff that he was “very motivated to make his situation
better”. When asked whether he had ongoing thoughts of harming himself, he
said “none, he would not want to hurt his family and doesn’t want to die”.
After the ACCT assessment had taken place, a senior officer from the wing
and the nurse from the inreach team held an ACCT case review. At the
meeting, she recorded about him, that “he has no intention to hurt himself and
is happy with life. He misses his family and hopes to overcome this with
visits”. Together with him, they decided to close the ACCT document and a
date was set for a post-closure interview with the nurse.
27. On 9 June, a second officer from the Offender Management Unit completed
the man’s “Remand Information” form, which summarised his personal details,
including those of his legal representatives. The officer also noted the reason
that bail was refused on 6 June and the man was remanded, as follows:
“Witness intimidation/failure to surrender.”
28. The man moved off the induction wing on to another residential wing on 11
June. At his initial remand planning meeting, the second officer recorded that
a bail application was going to be made. A member of the Youth Offending
Team (YOT) attended the meeting and agreed with the planned course of
action. Despite the application, the second officer set a date for the next
remand planning meeting as 2 July.
29. The man earned a basic weight training award on 16 June and settled into life
on the wing. The same day, a post-closure ACCT interview was held with the
nurse from the inreach team and he reported “doing fine, waiting for phone
credit”. He told her that he had “no thoughts of self harm”. The document
remained closed. The following day he was moved to another unit, where he
remained for less than two weeks.
30. At the remand care plan meeting on 2 July, the man was encouraged to
attend the Prisons Information and Communications Technology Academy
(PICTA), use the gym and maintain contact with his family on a regular basis.
In accordance with national requirements, his mother was invited to attend the
meeting and did so. He told those present that he had no thoughts of self
harm or suicide and he had no problems with other trainees. His next court
date was recorded as 18 August.
31. The man moved to F wing on 4 July. During his first night on the new unit, an
officer observed that he was “tearful on association”. He said he had no
10
thoughts of harming himself but that another young person had been verbally
abusive towards him. Although he would not identify the young person, he
was advised to report any similar behaviour to staff in future. After this
incident, he appeared to adjust to the routine of the prison and earned himself
enhanced status on 27 July. (The Incentives and Earned Privilege, or IEP,
scheme is a system to encourage behaviour by rewarding good behaviour
with benefits. There are three standards that prisoners can achieve, that is
basic, standard and enhanced.)
32. The second officer chaired a review of the man’s remand plan on 31 July, and
recognised: “The man has maintained an excellent standard of good
behaviour and positive attitude.” Again, he reassured those present that he
was not thinking of harming himself and had no trouble with other young
people. He continued to maintain regular contact with his family and achieved
those objectives set out in his remand plan.
33. On 18 August, the man was assessed as fit to appear at Crown Court and
pleaded guilty. As his date of birth was 31 August, he had turned 18 and
could be sentenced as an adult. The judge adjourned the case to wait for
psychiatric reports, before sentencing him.
HMYOI Glen Parva
34. Instead of returning to Feltham after a further appearance at Crown Court, the
man went to Glen Parva on 8 September. The Prisoner Escort Record (PER)
is a record of all escorted journeys made by a prisoner. It also includes a
section highlighting any known risks involved in moving that prisoner,
including potential medical issues. The PER, dated 8 September, for his
journeys from Feltham to Crown Court and then to Glen Parva. It noted that
he had a closed ACCT document because of the previous risk that he would
harm himself.
35. At the first reception healthscreen at Glen Parva, the man told the nurse about
his overdose on New Year’s Eve 2007. The nurse noted that he was an
“occasional drinker” and that he had received treatment from a psychiatrist
outside prison. He said he had no “thoughts of deliberate self harm”. She
recorded that she had received his clinical record from Feltham. The nurse
made no referrals following the healthscreen. The third officer, who
completed the Cell Sharing Risk Assessment (CSRA) undertaken in order to
determine whether it is safe for a prisoner to share a cell, noted “previous
threats of self harm but [no] thoughts of s/h [self harm] at present. Will share
with a decent lad.” The man was assessed as a medium risk and therefore
would be allowed to share a cell. The wing history opened for him on
reception at Glen Parva records that he had suffered a recent bereavement,
specifically of a “close friend last year, uncle and nan’s sisters”.
36. The man adjusted well to life at Glen Parva and his “good conduct” was
frequently remarked upon in his wing history. He applied himself in education,
with one teacher noting, “an excellent student. Works really hard. Completed
two courses in a very short period of time.” In just over a month, he had not
11
only earned enhanced status, (such status is not automatically awarded after
a transfer between prisons), but found himself on the enhanced landing. He
was employed as the unit cleaner, which is a position given to the most
trusted prisoners because it allows more freedom of movement around the
wing.
37. During an appointment with CARATS (the Counselling, Assessment, Referral,
Advice and Throughcare Service which is a non-clinical treatment programme
for prisoners who misuse drugs or alcohol) on 10 November, the man told
staff that he “was feeling a bit depressed but is generally ok and says he won’t
hurt himself”. Nevertheless he was referred to the mental health team. Three
days later, he had a long conversation with a worker from the team. She
noted that he felt “remorseful” and that “had he not been under the influence
of alcohol then he may not be in prison now”. She discussed the possibility of
him taking anti-depressants and he agreed that it might help him.
38. A prison doctor assessed the man on 17 November. He found that the man
was suffering from “poor sleep, lack of drive, feels let family down, etc”. He
told the doctor that he had no thoughts of harming himself. The doctor
prescribed 20 mg fluoxetine (an anti-depressant) to be taken daily. (The
recommended dose is 20 mg for someone who is starting to take anti-
depressants for the first time. The dose is usually reviewed after four to six
weeks.) The doctor specified that the man could hold one week’s worth of his
prescription in his possession at a time and that the prescription should be
reviewed in four weeks. He also noted that the man needed “mental health
support”. In their response to the draft report, the family told my investigator
that they were concerned that he was allowed to hold medication in
possession, despite his history of attempting an overdose. I understand the
family’s concern; however, as he was not considered to be at risk of self harm
at this time and the decision was made by an appropriately qualified
professional, I do not think that it was unreasonable to prescribe him in-
possession medication.
39. The next day the man had another appointment with CARATS and this time
no issues were reported. However, over the following days, staff noticed that
his “attitude to work was slipping”. Although employed to clean the third floor
landing, he would often be found in the kitchens. An officer challenged his
behaviour on 25 November. Despite this warning, on 29 November, the
officer recommended that the man’s IEP status be downgraded from
enhanced to standard due to being “complacent in his attitude”.
40. That same day, the man asked to see the mental health inreach worker. He
admitted that he was “struggling with [his] mood at the moment”. When asked
what was bothering him, he said that he could not get a visiting order for his
brother who had flown from Ireland to visit his family. (Every convicted
prisoner is allowed two hour-long visits every four weeks and is given visiting
orders accordingly. A visitor must have a visiting order before they are
permitted to see the prisoner.) He told her that he intended to move to Ireland
when he was released and become a chef in his brother’s business. She
spoke to the officer who agreed to help him get a visiting order.
12
41. Two days later, on 1 December, the man became angry when he asked to
make a telephone call and was told to wait. The officer wrote a lengthy entry
in his wing history record, regarding his “extremely poor attitude”. As a result
of this exchange and his worsening behaviour, the officer told him that he
would no longer be employed as a unit orderly and he would have to move to
another landing that was not exclusively for enhanced prisoners.
42. The following day, the man appeared at Crown Court. He was not sentenced
because the forensic psychiatric assessment had yet to take place. The
hearing was adjourned to 11 December. A psychiatrist completed a
psychiatric assessment on 3 December at the request of the court.
Unfortunately, the Ombudsman’s investigator did not have a copy of this
report for the purposes of the investigation. However, the psychiatrist made a
lengthy entry in the man’s medical record with his findings, which was
available for my investigation.
43. In his entry, the psychiatrist noted the man’s family history of abuse, although
he had always been supported by his mother and grandmother. He was
about six years old when he was first taken into care and endured nine foster
placements over just a few years. It was while he was in foster care that he
first drank alcohol and took drugs. By the time of his arrest, he described
himself as a regular drinker who would use cocaine once or twice a week. He
eventually returned to the custody of his family. He explained that he took the
overdose on New Year’s Eve 2007 because he was “hammered” and saw “no
point in being around anymore”. He assured the psychiatrist that he would
not consider taking an overdose again because he “had his whole life ahead
of him”. He told the psychiatrist that his meetings with the inreach team
worker were the first opportunity he had to “get things off his chest” and he
appreciated that. He said that he had been prescribed anti-depressants
because of his lack of appetite. He described in some detail the
circumstances of his offence and concluded that he was “disgusted” with
himself. He said “I want to get punished for it” and “I’m disgusted with what
I’ve done”. The psychiatrist concluded that the man did not have a mental
illness.
HMPYOI Woodhill
44. On 11 December, the man was sentenced to seven and a half years at Crown
Court. Rather than returning to Glen Parva, he was transferred to HMPYOI
Woodhill. During the course of the investigation, the investigator met the
man’s friend, and had since been moved to Wellingborough. He was
remanded to Woodhill for a short time before the court appearance. He
explained to the investigator that the man wanted to stay with him because
they were “as close as brothers”. The man was not returned to Glen Parva,
but was taken to Woodhill. When the investigator met the man’s mother, she
thought that he wanted to return to Glen Parva. She was concerned that he
should have returned to Glen Parva to continue the treatment for depression.
The investigator spoke to the Head of Healthcare at Glen Parva who
explained that, given the routine nature of his prescription, it was unlikely that
13
he would have been put on clinical hold. (Clinical hold means that the man
would have been specifically held at Glen Parva for a medical reason.) There
is no record of whether he was expecting to return to Glen Parva or not.
45. The PER dated 11 December covering the man’s journeys from Glen Parva to
Crown Court, and his transfer to Woodhill recorded the closed ACCT for self
harm risk.
46. The first reception healthscreen process at Woodhill differs for prisoners who
have transferred from another establishment. The man’s “Transfer-in
Reception Screening document” noted that he had been diagnosed with
depression and was taking 20mg fluoxetine. No immediate health concerns
were identified and no subsequent referrals were made. The CSRA
undertaken on reception at Woodhill identified him as ‘low risk’ and, recording
no open ACCT and no concerns, assesses him as suitable to share a cell.
47. The day after the man’s arrival, an Initial Classification and Allocation (ICA)
form was completed. This form is completed for any young offender aged 18
to 21 years to determine their security category and the most appropriate
prison to transfer them to. According to this assessment, he was “currently on
an open ACCT” but with a “review just completed with view to closure”. This
ACCT document was made available to the investigator after his death. He
told the officer that he would like to remain near to his friend, who was also at
Woodhill. The ICA form records the decision to transfer him to Aylesbury.
48. During his interview for this investigation, the man’s friend recalled the seven
days that the two young men spent at Woodhill. He said that when the man
arrived, he was honest about the nature of his offence. Despite the non-
sexual nature of the conviction, other prisoners at Woodhill misunderstood
him and thought he was a sex offender. The friend said that he experienced
no physical aggression personally, but he noticed that prisoners were
intimidating the man. On one occasion, the man was followed into the shower
area by four other prisoners. The friend said that there was no physical
violence during the exchange but the man was shaken by it. He and the man
were moved to another wing where they shared a cell. The friend told the
investigator that the man was much happier after the move. However, he
thought it would be better for the man if he moved to another prison. He
explained to him that he was 20 years old but could still spend nearly another
year in a YOI with him. The man and his friend approached staff who agreed
to transfer them to the nearest YOI, which is HMYOI Aylesbury.
49. The man’s medical record was reviewed on 16 December. He was judged fit
to transfer to another prison. This was also the date that his fluoxetine
prescription was due to be reviewed. There is no evidence that the review
took place. The investigator has not seen any prescription charts for the
seven days he spent at Woodhill, despite several requests for these records.
HMYOI Aylesbury
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50. The man was transferred to Aylesbury on 18 December. The PER document
covering his transfer from Woodhill to Aylesbury records that an ACCT
document had been closed on 12 December, that is the day after his arrival at
Woodhill. A nurse told the investigator that the prescription chart, ACCT
document and a supply of fluoxetine did not accompany the man from
Woodhill.
51. During his first reception healthscreen at Aylesbury, he told the nurse that he
was “having thoughts of self harm”. He said that he “was worried about
people finding out about his offence”. He told the nurse that he was bullied
while he was at Woodhill. The nurse said that she was aware that he had
been on an ACCT document while he was at Woodhill and that she “did look
for it” but could not see it in his records. The nurse did not contact Woodhill or
try to obtain a copy of the ACCT document. During interview, she
remembered he said that he was not thinking of killing himself because he
“did not want to die”.
52. Despite the man’s denial, the nurse spoke with the Senior Officer (SO) and
they agreed to open an ACCT document due to his “low mood”. Whilst she
did not refer him initially as part of the healthscreen, a referral was made as
part of the ACCT immediate actions. The other immediate actions included
locating him close to his friend, hourly observations and four conversations a
day, access to the Samaritans telephone, which he declined, and to a
Listener.
53. As a matter of routine, all prisoners are told about the Listener scheme when
they arrive at Aylesbury. He asked to speak to a Listener that first night. The
Listener saw him in his cell that evening. During interview with the
investigator, he said that the Listener scheme is well supported at Aylesbury,
however for security reasons, contact with prisoners at night must be
conducted over a telephone system.
54. The man had a secondary healthscreen on 19 December and was then
returned to the wing for his ACCT assessment. A second SO was the reserve
ACCT assessor that day. In order to become an assessor, he had
undertaken a five day training course, including a short introduction to mental
health awareness. During interview, the SO described the role of ACCT
Assessor as “to see if they can help identify what problems they have at the
time and what has caused them to self harm”. A third SO tried to contact the
duty ACCT Assessor to carry out the man’s assessment, but he was
unavailable. As the second SO was working on the neighbouring wing, the
third SO asked him to carry out the assessment.
55. The second SO explained to the investigation team that the ACCT
assessment took place in a private room on the wing. He spoke to the man
about what was bothering him and whether he had any thoughts of self harm
at that time. He recorded that the man had only been recently sentenced and
that his main concern was about other prisoners finding out about his offence
as he had been bullied at Woodhill. He told the investigator that the man was
worried that others might find out about his offence, not that they had or that
15
he felt currently at risk from other prisoners. He explained the support which
was available at Aylesbury for dealing with this, including the Listener scheme
and Samaritans, the possibility of moving to the vulnerable prisoners unit, and
support from staff. The man indicated that his ‘brother’, his friend, was a good
source of support and if he had problems he would go and speak with him.
56. The man did not discuss his offence in any great detail during the
assessment; however he did tell the second SO that he had been having
“flashbacks” about it for some five months. The SO recorded this and
believed that he had the flashbacks at night. In the assessment the SO
specifically recorded that the man was not “hearing voices telling him to do
anything” and that he had told him he “feels ok”. The man did not mention
anything to do with medication, nor did the SO know whether he was
receiving any support regarding these flashbacks.
57. Following this interview the second SO assessed that the man was not at risk.
He recorded him as saying that he had “no thoughts of killing himself, feels
not worth it as he has his life ahead of him … don’t want to be dead”. The
senior officer told the investigator that the man was quite positive about the
future. Discussing his previous suicide attempt, he said he did not want to die
as he had a lot to live for and would still have his life ahead of him. He would
only be 22 when released, and he had a lot of support from his family, mother
and step-father.
58. The ACCT review was undertaken immediately following this assessment,
attended by the third SO (who as unit manager chaired the meeting), the
second SO, the man’s personal officer and the man. There is no evidence
that healthcare was invited to the review meeting, or made any written
contribution. Neither the second SO nor the personal officer knew there had
been an ACCT opened and closed at Woodhill the previous week. The man
is described as coming “across shy but then had good eye contact and
contributed well”. The third SO recorded systematically that the man was able
to describe what support was available to him, said he was not likely to harm
himself, agreed that his risk was now low, and wanted the ACCT plan to be
closed. The man said he had had a “good think last night and would not do
anything like harming himself”, and that he wanted to be at Aylesbury and felt
better since the transfer. Despite not consulting anyone involved when the
ACCT was opened, those present agreed to close it, with the expectation that
the man would use support and speak to staff if needed. The third SO set a
date for the routine post-closure ACCT interview with the man on 26
December.
59. On 22 December, the man had an appointment with the doctor working at
Aylesbury. He told the investigation team that he was unaware that the man
ACCT had been closed when he saw him. He had not participated in the
decision to close the ACCT. He believed he was referred to him due to the
need for medication and because he was being monitored on the ACCT
procedures. He confirmed to the investigator that he had access to the man’s
continuous clinical record, but neither his previous prescription chart nor the
psychiatric report, and had written requesting a copy.
16
60. In assessing the man, the doctor said that in contrast to descriptions in the
notes of a very unhappy person “I thought this man was positive … I came
across a very positive looking person”. The doctor did not assess him as a
high risk of self harm. He told the investigator that he was struck by how
positive the man was during his assessment. For example, the doctor noticed
good body language and eye contact, the man told him about having family
support, clear future plans (his ambition to become a chef in his brother’s
planned restaurant), fluid conversation, and a pattern of mood variation which
gave little cause for concern. The man asked to stop taking fluoxetine, and
the doctor agreed that he could. However, he continued to prescribe the
antidepressant indicating that the man could resume it if he needed, and also
allowing time for a fuller healthcare assessment as he settled at Aylesbury.
61. There is no record that the man took any fluoxetine whilst at Aylesbury. His
wing history between 19 and 26 December is sparsely completed. Most, but
not all, the first week’s induction modules had been completed by 23
December. A fourth SO, who undertook the diversity induction as a group,
told the investigator that the man seemed relaxed with other prisoners and
she had no cause for concern about him.
62. On 20 December, the wing occurrence book records that the man and his
friend approached staff about concerns that other prisoners knew about the
man’s offence and were shouting about it through the windows. The man’s
personal officer told the investigator that he remembered that the man had
expressed this concern on one occasion. He said that the man could not
identify who had shouted to him. He advised him that if any physical threats
were made, staff would be able to challenge them but there was little they
could do about an unidentified person shouting. A fifth SO recorded that staff
checked whether there were any self harm thoughts and found none, and that
the man was advised to speak to staff if any threats were made to him.
63. The man’s personal officer said that staff were considering locating him on the
vulnerable prisoners unit due to the profile of his offence. He had not
discussed this with the man and he was not aware if other staff had. The third
SO told the investigator that he believed he had discussed this incident with
the man who perceived that the shouting was about him. He had discussed
with both the man and his friend their previous experience of bullying at
Woodhill. He remembered that the man was happy to be at Aylesbury, “I
perceived a real change in his demeanour, I think he was quite relieved to be
removed from that environment”.
64. The chaplain interviewed the man on 22 December. He recalled that he
expressed concerns about other prisoners finding out about his offence and
discussed what happened at Woodhill, said that he wanted to share a cell with
his friend, and expressed remorse over his offence. The chaplain reassured
him about Aylesbury’s non-tolerance of bullying policy. He indicated that,
because of the Christmas period, the cell sharing request would take time to
process. He suggested that the man should come on the chaplaincy’s victim
empathy programme to work through his remorse, which he agreed to do.
17
The chaplain found him positive about his plans to work as a chef with his
brother on release. As there were no thoughts about self harm nor allegations
he had been bullied, he saw no need to raise an ACCT or complete a security
information report. Nevertheless, he made a point of seeing the man again on
24 December, when he found him in a good mood and saying “I have no
problems at all”.
65. The man’s other personal officer told the investigator he met the man and his
friend for the first, and only, time on the evening of 23 December. He recalled
that the man said he was generally alright, but both he and his friend seemed
a little agitated. The man’s main concern was to share a cell with his friend.
He advised them both to make an application, and explained the risk
assessment takes time to complete, even though they were friends.
66. The man attended the healthcare centre again on 24 December. He gave
consent and received a routine Hepatitis B vaccination. There is no record of
any other health concerns being raised.
Events of 25 December and 26 December
67. The fourth SO was the senior officer on duty on D wing on 25 December. She
told the investigator that as it was Christmas Day prisoners were on
association all day. (Association is when prisoners leave their cells and mix
with each other on the wing.) After breakfast, prisoners were unlocked from
about 9.00am until midday, and then from 1.30pm until about 4.30pm. She
recalled that both the man and his friend stayed around the tables in the
middle of the wing, playing games all day. In the morning, an officer played
chess with them, and she described them as “very jolly” with no sign of
depression or anxiety. She remembered they went to use the telephone
several times, and seemed quite relaxed. She saw them mixing with other
prisoners, and no concerns were expressed about other prisoners knowing
about their offence.
68. The first personal officer was on duty in the afternoon, and he played draughts
with the man. He recalled the man making a telephone call. He described
him as neither being “upbeat” nor “down” but just “normal”. The man did not
appear anxious, and there had been no discussion about other prisoners
knowing or talking about his offence. Later in the day, the nurse happened to
meet him on the wing. She had a brief chat with him and described him as
seeming “much brighter” than when she had seen him on reception. In
response to her asking how he was, “he said ok because I have got my friend
and he wasn’t too bad”. Despite the man’s mother’s concern that he was
subject to bullying that afternoon, there is no evidence to support this.
69. The night officer for D wing arrived on the wing about 8.30pm and no issues
of concern were reported to him at handover. In ‘night state’ the officer makes
a routine observation check, through the cell door observation panel, on all
prisoners at intervals of between two to three hours. He told the investigator
that he checked all the prisoners just before 9.00pm and again at 11.00pm.
He did not recall specifically whether the man was either sitting on his bed or
18
watching television during these first two checks. He said that he had no
cause to speak to him. He said there had been some shouting out of the
windows earlier in the night, but he did not hear anyone calling the man’s
name, nor anything about offences or anything that could have been
considered bullying. He remembered that it quietened down quite quickly
between 9.30pm to 10.00pm, and remained so. He said he had no cause to
warn anyone to be quiet.
70. The man’s friend, who was located in a cell next door but one to the man’s,
told the investigator that he and the man had given each other Christmas
cards just before lock up and that he had replied “yes I’ll see you in the
morning” to him. He said he had later called out through the window to him at
about 1.00am and, having received no reply, asked one of the officers to go
and check on him, which they did.
71. At 1.48am, during his round of observational checks, the night officer opened
the observational panel on the man’s door and turned on the night dimmed
light. He saw him hanging and immediately used his radio to issue a Code
Red alert. (A Code Red alert is used when there is a serious self harm
incident that requires emergency and medical assistance.) The officer then
opened his sealed key pouch in readiness to open the door once assistance
arrived. (The prison policy is that a single officer on a wing may not enter a
cell alone.)
72. The night orderly officer’s role meant that he was the senior officer
operationally managing the prison during the night. He had just left the
healthcare centre when the call came through. He returned to the centre to
collect the nurse and help her carry the emergency equipment. A senior staff
nurse followed the orderly officer, along with two assistant orderly officers, to
D wing. During interview for this investigation, the night orderly officer
guessed that it had taken the four members of staff “less than a minute” to get
to the man’s cell after hearing the Code Red alarm.
73. The senior officer went into the cell, accompanied by the night officer. The
officer cut the ligature while the night orderly officer supported the man. The
night orderly officer noticed that the man was in such a position that his arm
was caught under and around a hot pipe running along the wall. When he
freed the arm, he noticed red marks and a further mark on the man’s side,
which explains the marks that his mother noticed after his death. Once on the
floor, the staff nurse asked for him to be moved from the cell to the landing to
provide sufficient room for the attempts to resuscitate him.
74. Though she found no pulse and the man was not breathing, the staff nurse
noticed that he was still warm. On checking his airway, she found no
obstructions, so she began cardio-pulmonary resuscitation (CPR). The night
orderly officer gave cardiac massage while the nurse used an ambubag (a
self-inflating device used instead of mouth to mouth). At the same time, she
asked for an ambulance to be called. The first assistant orderly officer called
for an ambulance. The staff nurse attached the defibrillator (a machine that
applies electrical impulses to the heart and advises whether there is any
19
rhythm which might be stimulated) which indicated there was no rhythm, so
the man should not be shocked.
75. The ambulance arrived at Aylesbury at 1.56am. The night orderly officer was
carrying out chest compressions at the time that he received a radio call to
inform him that the ambulance had arrived at the prison. As the orderly officer
he was the only member of staff to keys that enabled him to move between
wings, so he was required to go to the prison gate and escort the paramedics
to the cell. The first assistant orderly officer took over chest compressions.
The night orderly officer arrived back at the cell. The nurse explained that
staff continued chest compressions and administering oxygen until the
paramedics had set up their equipment. She remembered that the
paramedics changed the defibrillator leads to those of an electrocardiogram (a
device used to test the electrical activity in the heart). She thought that they
checked for activity three times. Having undertaken necessary tests, the
paramedics they confirmed that the man had died at 2.05am.
76. After he had been confirmed dead by the paramedics, the night orderly officer
asked whether the man could be moved back into his cell. The senior officer
told the investigation team that the paramedics said that he had to remain on
the landing until both police and the duty doctor had arrived. Conscious of
other prisoners being able to see the scene and as a mark of respect, the
night orderly officer instructed the lights to be put out, and a blanket placed
over the man.
77. The Governor, Deputy Governor and Duty Governor that night, arrived at
2.37am. The police then arrived at 2.55am and the duty doctor at 4.35am.
The police undertook their necessary investigation, including informing the
coroner, and called the undertakers at 5.05am. The duty doctor confirmed the
man’s death at about 4.55am and she and the ambulance then left the prison.
The man remained on the landing until 6.05am when he was taken away in an
ambulance.
78. The police made two written documents available to the investigator which
had been removed from the man’s cell during their investigation. The first
was an undated letter he had written to his sister apparently on Christmas
Day, but which was unsent. The second document was an application form to
see the chaplain which was dated 25 December, which had not been handed
in. In this letter he expresses being “upset” about his sister, one of his co-
defendants, being sentenced to such a long sentence and “also it is nearly a
year since [the mans close friend who died following an overdose] died and I
wish I could just go up to his grave and have a chat with him”. The letter also
requests she send him a stamped envelope and looks forward to their
release. The application reads “I need to have a chat with someone from the
chaplain as soon as possible”.
20
Support for prisoners
79. After she stopped her resuscitation efforts, the staff nurse heard the man’s
friend calling in a distressed state from his cell, asking if the man was all right.
The nurse spoke to him through his cell door. She recalled telling him that
she was very sorry but they believed the man had died and there was nothing
more they could do for him. She told the investigation team that, “due to
security restrictions”, she could not open his door at night. (During the night,
the prison is in patrol state which means that the night orderly officer must
give permission before a cell is unlocked.) Nevertheless, she said she spoke
to him for some time and asked him if he smoked. When he said that he did,
she rolled a cigarette and slid it under this door. After talking to him, she
talked to some other prisoners who had been calling through their doors.
80. Individual support was organised for the man’s friend from 26 December
onwards. An ACCT document was opened, but he told the investigation team
that he was uncomfortable with so much attention from staff. The ACCT was
closed shortly afterwards. Other prisoners were offered support during the
day with wing visits from chaplaincy staff, and time to associate and discuss
any issues with the staff.
81. A second chaplain arrived at about 3.15am. She prayed over the man and for
his family and friends. She told the investigators that she then spoke to the
man’s friend a number of times, as did the night officer. After the police and
doctor left, she and the officer ensured that the man was covered more fully
with another blanket until the undertakers arrived.
Family liaison
82. A Detective Inspector spoke with the duty governor and offered that the police
could inform the man’s next of kin. The duty governor accepted the offer. In
the morning, the duty governor learned that a member of his staff had been
trained in family liaison and appointed him as the Family Liaison Officer, with
the second chaplain as deputy.
83. The man’s mother was informed of his death by the police at her home at
10.15am on 26 December. The prison Family Liaison Officer had decided to
inform his mother personally but was unable to do so before the police had
arrived. He checked with the undertakers and the mortuary to establish when
the man’s mother could visit her son, before contacting her by telephone at
2.30pm. The Governor had already telephoned the man’s mother in the
morning to offer his condolences. Unfortunately, the news of his death was
reported in the local press. His mother was not aware that this could happen
and was surprised that the prison had not warned her. Although there is no
requirement for a Prison Service family liaison officer to mention the possibility
of media coverage, I hope some consideration will be given to doing so in the
future.
84. The Family Liaison Officer liaised with the coroner’s office, the funeral
directors, and the police, and maintained regular contact with the man’s
21
mother. She instructed that she wanted the funeral arrangements to be made
through the funeral directors who organised the funeral for her other son. She
asked to see the cell where he died and the visit took place on 31 December.
The man’s mother was accompanied by her brother, and the man’s friend was
allowed to join them. The Family Liaison Officer sought to answer her
immediate concerns about events, and undertook to investigate some of
these concerns. He subsequently explained the purpose of the coroner’s
inquest and the Prisons and Probation Ombudsman’s investigation.
Regrettably, due to the time taken for the post-mortem, but particularly delays
by the funeral directors, the man’s mother was unable to visit him until after 7
January. The Family Liaison Officer had liaised with the funeral directors
seeking to resolve this issue. He represented the Governor and staff of
Aylesbury at the man’s funeral which was held on 13 January.
Support for staff
85. A ‘hot debrief’ was convened by the duty governor, at 8.10am on 26
December. The meeting was intended to enable staff involved with the man
during the night to express immediate feelings and identify any learning
issues. All staff interviewed told the investigation team that it was a helpful
meeting. The duty governor requested that a representative of the prison’s
Care Team attend the following night to speak with staff individually. A few
weeks later, a critical incident debrief was held and any staff who had come
into contact with the man were invited. Again, the purpose of this meeting
was to allow staff to find support and also to distil lessons to be learned.
22
ISSUES
Clinical care
86. As noted above, a clinical review was undertaken on behalf of the local
Primary Care Trust. The panel appointed a clinical reviewer as the Chair. I
note the clinical review panel’s opinion that neither the absence of the
prescription for the antidepressants nor its abrupt cessation following his
transfer to Aylesbury contributed to the man’s risk of suicide.
87. The review panel makes 14 recommendations which I endorse, and do not
repeat here. The recommendations concern the man’s medical records, the
assessment of risk of self harm and the ACCT process, continuity of medical
care, emergency response, debriefing and training. I hope that the review
sufficiently addresses the man’s family’s concern about the quality and
content of his medical record. I commend the recommendations to the
attention of the Head of Healthcare and the Governor.
88. I agree with the panel findings in respect of the medical records and continuity
of care. Furthermore, it is clear that in addition to failing to send a prescription
chart, with what can only be described as inadequately completed medical
records, on the man’s transfer to Aylesbury, no arrangements were made to
provide his antidepressant. It is not clear that his prescription of fluoxetine
had been reviewed prior to his transfer to Aylesbury, although he had been
deemed fit for transfer at Woodhill. I am concerned that neither the doctor nor
the first reception healthscreen nurse followed up the missing prescription
chart, medication review or lack of medication at reception.
89. In the event, the man arrived at Aylesbury without his prescription or
medication. Medication for young adult prisoners at Aylesbury is ordered from
the pharmacy at Woodhill. During interview, the prison doctor told the
investigation team that it can take two or three days for medication to arrive
from Woodhill. Had the man’s medication been appropriately reviewed and
that review effectively recorded, the prescription may not have lapsed as it
did. This is an unacceptable interruption in continuity of his care. I therefore
make the following additional recommendation:
The Head of Healthcare at HMPYOI Woodhill should review the system
of assessing medical fitness for transfer to ensure that all outstanding
medication reviews have been carried out and that there is no
interruption to the supply of prescribed medication.
ACCT processes and practice
90. The man’s ACCT document from Woodhill did not accompany him on his
transfer either. The Suicide Prevention Co-ordinator from Woodhill explained
to the investigator that the office who managed the man’s transfer, noted only
that he had a closed ACCT document. The system in place at that time at
Woodhill meant that the ACCT document was not flagged as necessary for
transfer. As the man’s wing file also did not accompany him either,
23
communication between Woodhill and Aylesbury about his level of risk failed
completely.
91. Prison Service Order (PSO) 2700 – Suicide Prevention and Self Harm
Management sets out the requirements for prisons to manage suicide or self
harm. When discussing prisoners transferring between establishments who
are on an ACCT document or in the post-closure phase of an ACCT
document, the PSO requires that “the closed ACCT Plan must accompany
them”. There is no evidence that a post-closure review took place while the
man was at Woodhill. Therefore, he was still in the post-closure phase of
ACCT when he was transferred to Aylesbury.
92. Since the man’s death, the Suicide Prevention Co-ordinator confirmed that
“remedial action” has been taken to correct the systems at Woodhill.
However, I am concerned that such important information was not effectively
transferred with him when he moved from one prison to another. The
information about the experience he had in Woodhill, and his consequent
anxiety about other prisoners discovering the nature of his offence, was never
formally communicated to staff at Aylesbury.
The Governor of HMPYOI Woodhill should check that robust
arrangements are in place to ensure that all ACCT documents, whether
open or closed, are transferred with prisoners to their receiving
establishment in line with PSO 2700.
93. The staff nurse, who completed the first reception healthscreen, said that she
understood that the man was on an ACCT at Woodhill, and she noticed that
she could not find the document in his records. Nevertheless, she did not
contact Woodhill to ask for it. The PSO makes it clear that the responsibility
for transferring documents lies with the originating prison. However, the nurse
understood the importance of ACCT documents. She told the investigation
team that she was concerned about his presentation during the healthscreen
and opened an ACCT document herself. I am surprised that she did not
contact Woodhill to ask about the missing document.
94. Neither the second SO, who completed the ACCT assessment at Aylesbury,
nor his personal officer, were aware that the man was recorded as having
been on an ACCT at Woodhill. The SO told the investigation team that he
would have contacted Woodhill to ask for the missing ACCT document, had
he been aware of its absence.
95. The first SO explained that neither the second SO nor the man’s personal
officer would have been aware of the missing ACCT document. At the time
that the man was at Aylesbury, a closed ACCT document was filed with a
prisoner’s custody records, and was not on the wing but in a central
administrative block. During his interview for this investigation, he explained
that the system is now under review, but at the time, there is no reason that
the staff would know to request the previous establishment for any ACCT
documentation.
24
The Safer Custody Manager and the Governor at HMYOI Aylesbury
should ensure that a system is introduced so that any missing ACCT
documentation is identified as soon as a prisoner arrives at the YOI and
followed up with the relevant establishment without delay.
96. On the man’s reception at Aylesbury, the nurse opened an ACCT document,
in consultation with the SO. PSO 2700 requires: “An ACCT Plan must be
opened in every case where the [reception] screen is positive for current
thoughts of self-harm, wherever the prisoner is located in the prison”. The
nurse recorded that she was concerned about his low mood and that he
presented a ‘raised risk’, or ‘medium risk’, of self harm. The immediate action
plan contained appropriate actions to manage this risk, and the ongoing
record shows that ensuring he was located as near as possible to his friend,
giving him access to a Listener, and implementing hourly observations with at
least four meaningful conversations a day. There was a further immediate
action, namely the referral to the mental health inreach team. There is no
record of his being interviewed by the mental health team, either before or
after the ACCT was closed the following day.
97. During the ACCT assessment and review on 19 December, the man
presented well to staff. He requested to be taken off the ACCT plan. The
review was chaired by the induction wing’s senior officer, who had not
previously met him. Also present was the second SO, the ACCT assessor,
who met him that morning. Neither the first SO nor the nurse was invited to
the review or to make a contribution, despite having been instrumental in
opening the ACCT document. (In their response to the draft, the family
expressed concern about staff at the review’s understanding of the purpose of
the ACCT document. This could have been avoided by inviting those involved
in opening the ACCT document to participate in the subsequent review.)
There is no evidence that anyone from the healthcare team were invited to
attend the review. One of the actions identified in the man’s immediate action
plan was to undergo a mental health assessment. It was still outstanding at
the time of the case review. The personal officer and the third SO told the
investigator that healthcare would have been invited to attend the review, but
there is no evidence to support this. In their response to the draft report, the
family expressed concern that his ACCT plan was closed without the mental
health assessment, specified in his immediate action plan, having taken
place.
98. The man did not mention during the ACCT assessment or review that he had
been prescribed and was taking antidepressant medication at Glen Parva and
Woodhill. There was no obligation on him to share confidential healthcare
information. However, given that healthcare were aware that his
antidepressant medication had been interrupted on his transfer to Aylesbury,
ensuring their advice was given to the review meeting was particularly
important. The prison doctor subsequently agreed with the man that he could
stop taking his antidepressant medication if he wished.
25
99. Whilst I understand the competing demands on healthcare staff in prison, the
importance of a multi disciplinary approach to those subject to ACCT cannot
be underestimated.
The Safer Custody Manager and the Head of Healthcare at HMYOI
Aylesbury should enable healthcare to contribute into all ACCT reviews,
where relevant.
100. That the man had a brother who had committed suicide by overdose was not
known to Aylesbury, or any of the institutions he had been in, until after his
death. Both at Feltham and at Glen Parva, questions were asked which had
elicited from him that he had suffered bereavements in the past year.
However, on neither of these occasions had he talked about his own brother’s
death. Whilst the second SO talked to him about his own previous suicide
attempt during the ACCT assessment, there is no evidence that he was asked
whether there was a family history of suicide. Undoubtedly a difficult question
to ask, nevertheless it might have been important in establishing any patterns
of risk. In his last letter to his sister, he mentions that the anniversary of his
brother’s death was approaching, and he wished he could go to his grave. A
family history of suicide is a significant risk factor. Young people under the
age of 18 who are in prison are often asked about any experiences of self
harm within their family. There is no evidence that he had discussed his
feelings about this with anyone, and it is sadly not possible to establish with
any certainty how this affected him.
101. Only the ACCT assessor had met the man before the ACCT case review
when the document was closed. He had arrived at the YOI in a “tearful” state
and felt better the following morning. He had never been to Aylesbury before
and knew none of the staff there. Whilst he presented well both in the ACCT
review meeting and generally on the wing in the week up to his death, I am
concerned how quickly the ACCT was closed. The flexibility of the ACCT
process means it can be used simply to record interactions at flexible intervals
according to the assessed level of risk, such as twice a day. The third SO told
the investigator that he had considered reducing observations and significant
conversations as ACCT actions rather than full closure. I am concerned that
the man’s ACCT document was closed so quickly after it was opened, and
after he had only been at Aylesbury for such a short time. I understand that
the third SO intended him to be monitored as part of the post-closure review
process, but I do not accept this to be an adequate substitute for the
structured support of an open ACCT document.
The Safer Custody Manager at HMYOI Aylesbury should review all ACCT
documents closed within one week of opening, with the expectation that
such quick closures should only happen in exceptional cases.
102. PSO 2700 advises that an ACCT should not be closed if there are outstanding
actions in the prisoner’s caremap. The third SO said that he had the action
plan on his desk during the week after he closed the man’s ACCT document.
The man’s mental health had not been assessed. This was identified as an
action in the caremap drafted when his ACCT was opened.
26
The Governor of HMYOI Aylesbury should remind staff that an ACCT
must not be closed while there remain outstanding actions in the
immediate action plan or caremap, in line with PSO 2700.
Cell sharing
103. The man was located in a single cell. PSO 2700 advises that “doubling-up of
an at-risk prisoner with a cellmate can help to reduce feelings of loneliness
and provide both with someone to talk to”. It was not possible to locate the
man and his friend together on the induction unit at Aylesbury, as they had
requested, as there is only one shared cell which is used by the cleaners.
They both had been risk assessed for cell sharing; however the prison policy
is to undertake a full assessment after prisoners have settled into the prison.
Therefore, officers at Aylesbury do not undertake such a review until a
prisoner has completed his induction.
104. Staff on the induction unit were considering the possible location of the man
on the vulnerable prisoners unit following induction, but had not discussed this
with him directly. While I acknowledge that he would have found support in
sharing a cell with his close friend, I do not think it was unreasonable of staff
to wait until they were satisfied that they could make a full assessment of the
risk that each prisoner presented.
Violence reduction and vulnerability
105. The man and his friend both said that the man had been subject to bullying at
Woodhill. There is little evidence of these allegations and the subsequent
investigation, but it seems that the problem was solved by moving both to
other wings within that prison. Officers then agreed to move them together to
Aylesbury. The man expressed his anxiety on a number of occasions that
other prisoners at Aylesbury had found out about his offence. He was worried
that it might be similarly misinterpreted as a sexual offence. From the
moment of his first remand into custody he had, in any case, expressed
serious remorse over his offence, which he discussed with the chaplain at
Aylesbury. His remorse, coupled with other prisoners’ misunderstanding of
the nature of his offence, is likely to have contributed to his vulnerability.
106. The man had alerted staff at Aylesbury to shouting out of the windows which
he perceived as being directed toward him and about his offence. He
approached his personal officer on 20 December in this regard. As he could
not pinpoint who had shouted at him, no violence reduction measures could
be taken. The personal officer reassured him they would consider moving
him for his own safety, if necessary. The exchange was recorded in the wing
observation book and the officer checked whether the man had any thoughts
of self harm, which he denied.
107. The man’s family told my investigator that he had spoken to his grandmother
on the afternoon of 25 December and he seemed well. They were concerned
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that his mood had deteriorated so dramatically in so short a time and were
worried that he may have been bullied that afternoon. In fact, there is no
evidence that there was a repeat of this behaviour on 25 December, although
the night officer recalled there was some shouting early in his night shift. The
officer did not recall anything specific to the man and heard nothing that he
needed to challenge. The man had been observed to be mixing well both with
staff and other prisoners that day, and had told the nurse at teatime that he
had no problems.
108. This is not the first Ombudsman’s report involving young adults feeling
targeted by shouting of other prisoners out of windows. The then, NOMS
Violence Reduction lead advised the investigator that such behaviour should
be considered as bullying and dealt with using violence reduction measures. I
make no separate recommendation here, but reinforce the recommendation
of the Chief Inspector that “all incidents of violence and assault should be
accurately recorded through the incident reporting system”. It should include
incidents related to shouting out of windows perceived to be intimidating.
These measures should enable the institution to plan appropriate actions to
reduce the incidence of intimidating shouting from windows. In respect of any
potential impact on the man it would also have been good practice to have
discussed with him directly that consideration was being made to move him to
the vulnerable prisoner’s unit so that he had a sense of planned response to
his concerns.
Emergency response
109. The response to the night officer’s discovery of the man and his call for
emergency assistance on 26 December was prompt and professional. There
was no significant delay caused by the policy that a single officer could not
open a cell door alone at night. Both the nurse and all necessary emergency
equipment arrived speedily at the cell. Due to the size of the cell, it was
appropriate that the man was moved out to the landing to enable staff to do
their best to resuscitate him. Both the nurse and uniformed staff made
considerable and careful efforts at resuscitation before the paramedics
arrived.
110. Once the paramedics had confirmed that the man had died, staff were
advised that he could not be moved until both the police and the doctor had
seen him. The night orderly officer took action out of respect for the man and
out of concern for other prisoners to dim the lights and cover him. However, it
was some two hours before the police and doctor were able to complete their
examination. The delay may have increased the distress for the man’s friend,
whose cell was nearby, and other prisoners. Dependant on the police
instructions, the man might have been moved back into his cell once the
doctor had finished. I make the following recommendation in order to
increase the mark of respect and decrease the potential for other prisoners’
and staff distress in similar circumstances.
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The Governor of HMYOI Aylesbury should make suitable provision for a
screen to be used in the event of a young prisoner’s death on the
landing at night and further promote dignity and respect.
111. There is evidence that substantial efforts were made by the nurse, officers
and the chaplain to speak with, comfort and reassure the man’s friend during
the night, despite his own recollection that he did not find out about his
friend’s death for several days. I am satisfied that specific assistance and
support was provided for him in the following days. I make no
recommendation here. However, after he was moved, opening his friend’s
cell and talking face to face might well have given him additional comfort for
the loss of his friend.
Family liaison
112. The duty governor arranged with the police during the night to visit the man’s
mother to inform her face to face of his death as soon as possible. PSO 2710
and the accompanying Family Liaison Officer guidance states that breaking
the news of a prisoner’s death should be undertaken wherever possible in
person by the prison family liaison officer. During interview with the
investigator, the duty governor acknowledged this as a learning point for
himself. I suggest therefore that the senior management team familiarise
themselves with National Offender Mansagement Service family liaison
guidance.
113. The morning after the man’s death, the duty governor appointed a governor
the family liaison officer. He, and Aylesbury’s Governor, contacted the man’s
mother as soon as possible after the police had informed her of her son’s
death. His mother and family were given support and assistance following his
death. The family liaison officer liaised closely both with the coroner’s office
and the funeral directors to assist the man’s mother as much as possible. It is
regrettable that so much time passed before she was able to visit her son, but
I am satisfied that the family liaison officer did all he could to reduce the delay,
which lay outside of his control. One learning point, however, is to consider,
in conjunction with the coroner’s office and the funeral directors, how to
prepare a family member for seeing injuries on their loved one.
114. The man’s mother expressed her thanks for the considerate way in which the
family liaison officer facilitated her visit to her son’s cell.
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CONCLUSION
115. The man’s custody was transferred from Woodhill to Aylesbury on 18
December. Staff at the receiving prison did not have all of the information or
medication they needed to exercise their duty of care for him. His full medical
history, prescription and previous ACCT document did not transfer with him.
116. Nevertheless, reception staff immediately identified that he was at risk of self
harm and required a mental health assessment. Those staff were not
involved in the decision to close the ACCT the next day. Support for
prisoners in the post-closure phase of ACCT is not a substitute for the fully
flexible, multidisciplinary support provided by ACCT monitoring. I hope the
Governor and the Safer Custody Manager work together to strengthen the
processes in place to safeguard young adults.
117. There is no evidence to suggest that the man was being bullied the afternoon
before his death. He was remorseful about his offence and feared that other
prisoners would misunderstand its nature. While it is not possible to
determine what was on his mind in the early hours of 26 December, he was
open to staff about the difficulty he had coming to terms with the offence he
committed and his time in prison.
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RECOMMENDATIONS
1. The Head of Healthcare at HMPYOI Woodhill should review the system of
assessing medical fitness for transfer to ensure that all outstanding
medication reviews have been carried out and that there is no interruption to
the supply of prescribed medication.
This recommendation was accepted. The response was:
“The Head of Healthcare will review the pre transfer assessment, and
include a section to confirm that all outstanding medication reviews
have been carried out and that the prisoners’ current medication is
suitable.”
2. The Governor of HMPYOI Woodhill should check that robust arrangements
are in place to ensure that all ACCT documents, whether open or closed, are
transferred with prisoners to their receiving establishment in line with PSO
2700.
The Governor accepted this recommendation with the following response:
“All closed ACCT documents will be stored in the prisoners 2050 file in
the discipline office immediately following the post closure review and
transferred with the prisoner to the new establishment. All open
documents will be taken to reception by the staff member escorting the
prisoner to reception and handed over to reception staff ready for
transfer.
In addition the safer custody team on a daily basis will check the
discharge list the day before and inform reception if any prisoners due
for transfer have been on an ACCT document within the last 30 days in
accordance with PSO 2700. Reception staff will then ensure that the
ACCT document is present prior to transfer.”
3. The Safer Custody Manager and the Governor at HMYOI Aylesbury should
ensure that a system is introduced so that any missing ACCT documentation
is identified as soon as a prisoner arrives at the YOI and followed up with the
relevant establishment without delay.
This recommendation was accepted with the following response:
“All young prisoners are interviewed by reception staff when they arrive
at the establishment. This interview is mandatory and is an integral part
of the Reception protocol. A system will be put in place for the specific
question of “have you been on an ACCT Plan?” as part of the
Reception interview. Reception Officers will check all documents to
ensure the previous ACCT Plan is available. If not available the Safer
Custody Coordinator will be informed as a matter of urgency to contact
the previous establishment to retrieve the ACCT Plan. Reception Staff
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will have the responsibility for ensuring that past ACCT Plans are
available. The same question will also be asked as part of the
Reception Board Interview and any deficiencies will be reported to the
Safer Custody Coordinator as a matter of urgency. At weekends or
Friday evenings, the orderly Officer will be notified to take action.”
4. The Safer Custody Manager and the Head of Healthcare at HMYOI Aylesbury
should enable healthcare to contribute into all ACCT reviews, where relevant.
Again, the prison accepted this recommendation and responded as follows:
“A discussion has taken place between the Safer Custody Manager
and the Head of Healthcare act on this recommendation. Where
relevant, Residential Case Managers will ensure that Healthcare are
invited to attend the reviews and record any apologies or failure of
attendance in the ACCT Plan (on the Record of Case Review). In the
circumstances of non attendance a written report will be requested for
the Case Review team to consider during the review.”
5. The Safer Custody Manager at HMYOI Aylesbury should review all ACCT
documents closed within one week of opening, with the expectation that such
quick closures should only happen in exceptional cases.
The Safer Custody Manager accepted this recommendation and responded
as follows:
“All ACCT Plans will be thoroughly checked post closure by the Safer
Custody Manager as part of the assurance process. Any that are
closed within one week of being opened will be brought to the Safer
Custody Meeting for discussion to establish and validate if there was
justification for an exceptional reason why closure occurred within
seven days.
The Local Suicide Prevention and Self Harm Management policy will
be reviewed to include the statement that “ACCT Plans should not be
closed within seven days of opening, except in exceptional cases” and
publicised by a notice to staff.”
6. The Governor of HMYOI Aylesbury should remind staff that an ACCT must
not be closed while there remain outstanding actions in the immediate action
plan or caremap, in line with PSO 2700.
The Governor has accepted this recommendation and responded accordingly:
“A notice to staff will be issued to inform staff of the need to ensure that
all actions on CAREMAPs are completed prior to closure of the ACCT
Plan. This will also be highlighted at the Safer Custody Meeting every
month during the feedback on closed ACCT plans.
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All ACCT Plans are checked by the Safer Custody Manager and any
deficiencies will be discussed at the monthly Safer Custody Meeting
and the weekly Residential managers meetings.”
7. The Governor of HMYOI Aylesbury should make suitable provision for a
screen to be used in the event of a young prisoner’s death on the landing at
night and further promote dignity and respect.
The Governor has agreed to this recommendation and set out the following
action:
“Screens are available in the establishment and will form part of the
contingency plan as an aide to use these if the need arises.”
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