Individual at Leeds

Investigation into the circumstances surrounding the
death of a male prisoner at HMP Leeds at Leeds
General Infirmary in March 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2010
This is the report into the circumstances surrounding the death of a male
prisoner from HMP Leeds, at Leeds General Infirmary on 27 March 2008.
The man had been found hanging in his cell at around 11.10am on the
previous day. Having removed the ligature, prison staff tried to resuscitate
him and managed to restore a pulse before he was transferred swiftly to
hospital. Sadly, the man did not recover from his injuries and he died in
hospital at 5.00am the following morning. He was 27 years old.
This investigation was led by an investigator from my office and written by
another investigator. I would like to thank the Governor of Leeds and his staff
for their participation in this investigation. I also thank Leeds Primary Care
Trust for commissioning a Doctor to undertake a clinical review. The
production of this report has been delayed because of staff changes within the
Ombudsman’s office, and because of a delay commissioning the clinical
review. I much regret any additional distress or inconvenience this may have
caused.
The loss of a loved one is always hard to bear. It is particularly so in this case
due to the family history, and as the man had young children. I offer my
sincere condolences to the man’s mother, partner, family and friends for their
tragic loss.
I make five recommendations to the Governor of Leeds.
Jane Webb
Acting Prisons and Probation Ombudsman
May 2010
CONTENTS
Summary
The investigation process
HMP Leeds
Key findings
Issues
Conclusion
Recommendations
SUMMARY
The man died serving a 30 months sentence at HMP Leeds.
Prior to his arrest and conviction, two of the man’s brothers committed suicide
by hanging. The man found them both and had to cut them down. During his
time in prison, he had received news that two of his friends had also
committed suicide.
The man was first received at Leeds on remand on 3 August 2007. Initially,
he was assessed as being at low risk of harm to himself or others. However,
on 9 August, he attempted to hang himself. Prison staff intervened swiftly and
he was successfully resuscitated and transferred to hospital. An Assessment,
Care in Custody and Teamwork (ACCT) plan was opened on him, and he was
supported and monitored appropriately on his return to prison. He was bailed
from prison, pending sentence on 13 August 2007.
Over the next six months, the man received psychiatric care in the community
both on an inpatient and outpatient basis under his psychiatrist. He made a
number of further attempts at suicide whilst in the community.
The man was sentenced in February 2008, and arrived at Leeds prison later
in the day. An ACCT plan was immediately opened by reception staff and he
was first placed under constant observation, and then monitored for a longer
period than usual on D1 induction wing. The plan was closed on 21 February,
by which time the man had been located on a normal wing.
On 2 March, the man disclosed further suicidal ideas, and said he was being
bullied. He was relocated briefly to the healthcare unit under constant
observation, before being transferred back to D1 wing. He settled on D1 wing
and was given a job as a cleaner which he enjoyed.
The man was found to have stolen tobacco from his cell mate on 17 March.
He said that he was being bullied, but was unable to identify any individual.
Due to this abuse of trust he was moved to C wing, and lost his job, but he
was not placed on a disciplinary report as staff considered this would be likely
to increase his level of stress. A new ACCT plan was opened the same day
as he was relocated.
The man was moved to F wing on 20 March. The same day he learned that
another friend had committed suicide. At his mother’s request, a member of
staff spoke to him and the man gave assurances that he was coping. The
following day, the man disclosed to staff he had taken an overdose of his cell
mate’s medication, and he was taken to Leeds General Infirmary for tests and
monitoring. The man was received back at Leeds in the evening of 22 March,
blood tests having shown negative. His ACCT plan was reviewed and closed
on 24 March, but without a multi-disciplinary review. A post-closure interview
date had been set.
In the morning of 26 March, the man made an allegation of bullying and
assault against his cell mate. He was assured by an officer that this would be
investigated and he would be examined by a nurse later. His request for
transfer to another shared cell was going to be considered. The officer liaised
with the senior officer in respect of the allegation, and the senior officer
checked that the cell mate was on a visit at the time and not present in the
cell.
Before the allegation could be investigated, another prisoner went to the
man’s cell by chance, saw him hanging inside, and immediately alerted staff.
Both uniformed and clinical staff responded quickly, cut the man down, and
were successful at first in resuscitating him. The man was taken by
ambulance to Leeds General Infirmary.
Further treatment and tests were undertaken before the man was admitted to
the intensive care unit. Tests showed, however, that he had suffered a
severe brain injury. He died at 5.00am on 27 March with his family present.
I make five recommendations as a result of this investigation. The
recommendations refer to the ACCT process.
THE INVESTIGATION PROCESS
1. This investigation was originally allocated to a Senior Investigator. After
her promotion to Assistant Ombudsman a very short time later, it was
reallocated to a fellow investigator. He visited the prison and spoke to
staff who had come into contact with the man during his time in custody.
The investigator interviewed 12 members of staff. The interviews were
tape recorded and transcripts are annexed to this report. Copies of
these transcripts were sent to the interviewees to confirm that they were
accurate.
2. Following the investigator’s retirement, another Investigator was asked to
write the report. On reviewing the first draft of the report, another
Assistant Ombudsman considered that further investigation was needed
to address two particular issues. He arranged to interview a further two
officers at Leeds in October 2009. Unfortunately, neither officer was
available when the Assistant Ombudsman visited the prison (The
Investigator who later retired had also tried to speak to one of the officers
before his retirement). This has left several outstanding issues that I
mention later in the report.
3. Notices were posted to staff and prisoners about the investigation,
inviting contributions. Two prisoners were informally interviewed.
4. A clinical review of the man’s care was commissioned from Leeds
Primary Care Trust. It appears that they did not identify a medical
practitioner to carry out the review for some time, and this has
contributed to the delays in this case. However, I am grateful to Leeds
PCT and, in particular the Clinical Reviewer, for undertaking this review.
The investigators discussed aspects of the man’s treatment with
healthcare staff at Leeds and with the clinical reviewer.
5. The investigators contacted Her Majesty’s Coroner to inform him of the
nature and scope of the investigation, and to request a copy of the post-
mortem report which was received. Upon completion, the report will be
sent to the Coroner to assist with his enquiries into the man’s death.
6. One of the Ombudsman’s Family Liaison Officers, spoke to the man’s
mother, his partner, and two of his sisters, as well as to a close friend of
his family, and visited them at the start of the investigation with the initial
investigator who was later promoted. The Family Liaison Officer has
kept in close touch with the family through the investigation, and met the
family again in the summer of 2009 with the Investigator that wrote up
the report. It was during this visit that one of the additional issues was
raised.
HMP LEEDS
7. HMP Leeds is a category B local prison built in 1847. The prison serves
magistrates’ and Crown Courts in the West Yorkshire area, taking adult
male prisoners on remand until trial and for short periods after sentence.
Up to 1,004 prisoners are held on six wings including the healthcare
facility in accommodation certified to hold 674.
Previous deaths at Leeds
8. Sadly, there have been 40 deaths at Leeds since I was entrusted with
responsibility for undertaking death in custody investigations in 2004.
Although ACCT procedures have featured in the recommendations made
after three of these investigations, there are no direct similarities to this
investigation. However, as a result of one of the recommendations,
Leeds implemented a new system to measure compliance with ACCT
post closure procedures in May 2008.
Healthcare
9. The healthcare department includes a 20 single bed inpatient unit.
Healthcare staff at Leeds are commissioned and provided by Leeds
Primary Care Trust.
Her Majesty’s Chief Inspector of Prisons
10. HM Inspectorate of Prisons carried out an unannounced inspection of
Leeds in December 2007. In her subsequent report, the HM Chief
Inspector of Prisons found that reviews of ACCT assessments were not
sufficiently multidisciplinary and that ACCT caremaps were not well
targeted. She also found that there was a lack of primary mental health
provision and the in-reach team’s criteria were strict. These findings and
associated recommendations are pertinent to the circumstances of the
man’s death.
Independent Monitoring Board (IMB)
11. 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.
12. The latest IMB annual report for 2007-08 describes the prison making
progress in the areas of suicide prevention and violence reduction under
the co-ordination of the Safer Custody Group. I note that the IMB makes
particular mention of a ‘significant dates’ diary introduced to note
particular dates when prisoners could feel upset, distressed or
depressed, and that prisoners prone to self-harm could have increased
observations around their significant dates. This improved practice is
relevant to the recommendations made in my report.
Assessment, Care in Custody and Teamwork
13. Assessment, Care in Custody and Teamwork (ACCT) is a set of
procedures designed to reduce self inflicted death and self harm. It
provides assessment and care planning, personalised care and support
before, during and after a crisis experienced by a prisoner.
14. If observations are required, the ACCT assessor will decide what level of
observation is appropriate. This can range from constant observation
(where the prisoner will be watched at all times) to defined numbers of
meaningful contacts, for example a detailed conversation between the
prisoner and member of staff. Observations should be conducted
irregularly; for example, an hourly check should not be done at the same
time every hour).
Safer Custody Programme
15. The Safer Custody programme at Leeds is available on all wings and
has been in place since 2003. It is designed to help prisoners reduce
their levels of distress and to reduce the risk of self harm.
KEY FINDINGS
16. The man appeared at a magistrates’ court in August 2007, charged with
possessing Class A drugs with intent to supply, and property offences.
He was remanded in custody to appear a Crown Court at a later date
and was taken to HMP Leeds.
17. After going through induction at Leeds, the man appeared to settle well
and was placed in a normal wing. A Cell Sharing Risk Assessment
(CSRA) identified him as low risk and suitable for normal location.
18. However, on 9 August, the man made his first attempt at suicide. Staff
unlocking him for the afternoon workshops found him hanging from a
ligature made from a bedsheet tied to the cell window bars. They cut
him down, and called for medical assistance. Nursing staff arrived
quickly and placed him in the recovery position. The prison doctor
arrived shortly afterwards and found that he was breathing
spontaneously. He gave the man some medication and ensured that a
cervical collar was applied. The man was then taken by ambulance to
Leeds General Infirmary (LGI) at 2.50pm. A member of the prison
healthcare later contacted the hospital and was told that the man was
stable. She then telephoned his mother, advising her to attend the
hospital.
19. After treatment at LGI, the man returned to Leeds on 10 August.
Records indicate he was admitted to the Acute Assessment Unit there
for psychiatric assessment. There is no record that the assessment was
actually undertaken.
20. As a consequence of the man’s suicide attempt, an ACCT document was
opened on 9 August by a Senior Officer (SO). The ACCT action plan
included the need for general staff support and allowing him telephone
calls as required. A review of the ACCT was undertaken appropriately
by another SO on the man’s return from hospital the following day.
21. During the ACCT review, the man said that he had not planned his
suicide attempt but had waited until his cell mate had gone to education,
and that he “still wants to die” to be with his two brothers. The man
further explained that he hated being away from his family and felt prison
was “tipping him over the edge”. The reviewed action plan identified
constant supervision and a referral for bereavement counselling as
necessary.
22. The ACCT was closed with a revised follow up action plan after the man
was granted bail by the Crown Court and discharged from prison on 13
August. In accordance with the ACCT arrangements, the prison made
efforts when releasing him to ensure he was picked up by his mother at
the gate, and provided him with counselling agency addresses in the
community. It is not clearly recorded what discharge information was
provided to the man’s doctor in the community, although healthcare
records confirm that he was informed of his release. Before he was
released, the man was also seen by a counsellor, who provided further
information about opportunities for counselling in the community.
23. After his release, the man returned to live with his mother at home. His
doctor made a further referral to a Doctor at the Becklin Centre, and he
was seen again on 17 September. The Doctor wrote that the man
reported a low mood and describing ongoing suicidal thoughts but
without any active plans. The man saw his children as protective factors.
However, he clearly described that, if he were sent to prison, he would
kill himself. The Doctor diagnosed a Moderate Depressive Episode with
Prolonged Grief Reaction and prescribed the anti-depressant citalopram
and arranged a follow up appointment.
24. However, in early October, the man contacted the mental health duty
worker expressing suicidal ideas. He was referred to the South Leeds
Acute Community Service (SLACS) and attended the unit for three days.
He was then informally admitted to an inpatient ward at the Becklin
Centre as his risk was deemed too high. At one point he attempted to
strangle himself in his room. He was diagnosed as having an adjustment
disorder, but the assessment found no evidence of depressive illness.
He was discharged on 15 October.
25. A follow up community mental health assessment reported the man’s
persistent suicidal ideas and lack of engagement with community
services. On 3 November, the man was readmitted to the Becklin Centre
having attempted to hang himself from a tree. He was discharged after
two days and was not diagnosed with a depressive illness.
26. On 10 November, the man was readmitted to SLACS after he took an
overdose of his mother’s medication. He was later readmitted to the
Becklin Centre after a close friend killed himself on 16 November by
hanging. He made a further serious attempt to kill himself on 20
November in the ward bathroom. He explained that he had met
someone on the ward who knew his brother which had brought back
memories of his suicide.
27. The man was discharged again on 28 November with a diagnosis of
adjustment disorder. He attended an outpatients appointment on 18
December and it was noted that he had continuing thoughts of suicide
but without any active plans. He was complying with medication, which
now included olanzapine (an anti-psychotic drug sometimes prescribed
in a mild dose for people experiencing suicidal ideas).
28. The Doctor from the Becklin Centre saw the man for what was to be the
last time on 21 January 2008. He found no evidence of anxiety, suicidal
ideas, or formal thought disorder. He did find, however, that the man
exhibited a low mood due to the death of his brothers and his continuing
grief. He also said that he felt suicidal as he did not want to go to prison.
29. The Doctor prepared a psychiatric report for the court at the request of
the man’s defence team. He diagnosed him as suffering from an
adjustment disorder with a prolonged grief reaction as a consequence
both of the suicides of his brothers and his impending court case. He
identified the man’s suicidal ideas as directly related to his fear of being
sent to prison and said that they were not due to any treatable mental
illness. The Doctor concluded that there was a genuine risk that if the
man was sent to prison he would attempt to kill himself.
30. The man was sentenced to two and a half years imprisonment on 5
February 2008 at the Crown Court for the offences of possession of
Class A drugs with intent to supply. Due to the length of his sentence,
the earliest date for his conditional release would have been 24 April
2009, although he would have been eligible for earlier release on home
detention curfew from 11 December 2008. There is evidence that the
man was not expecting to be sentenced that day. He had only appeared
at court following an urgent telephone call from his solicitor. The family
believe the letter advising him of his sentencing date had been sent to a
previous address.
31. At the time of the man’s sentence, both the report from the Doctor and a
report from the local probation officer were available to the court. Both
identified the risk of suicide. The probation report highlighted the
imminent risk of suicide if he was sentenced to imprisonment.
32. Immediately following sentencing, the probation court duty officer at the
local Crown Court faxed HMP Leeds with a notification of concern of
suicide risk for the attention of the Governor. This included a copy of an
e-mail from the author of the probation report as well as a copy of the
probation report. Similarly, the prison court officer (PCO) completed a
suicide risk/self harm warning form which highlighted the man’s history of
suicide attempts. He felt depressed due to his sentence, but would tell
staff about his self-harm on arrival. This form was countersigned by the
reception officer when the man arrived at Leeds at 3.30 pm.
33. A CSRA was undertaken. It indicated that the man was a low risk to
others and suitable for location in a shared cell. However, the man was
also seen by a Nurse on reception who recorded that he was in a low
mood and said that he wanted to die and would take his life at the next
opportunity. She recorded a high score of 11 on the suicide risk
assessment. (There are several different scoring systems used clinically
to determine the potential risk to a patient.) He declined the support of a
‘Listener’ (Listeners are prisoners who are trained by the Samaritans to
offer a confidential service to other prisoners) and access to the
Samaritans telephone line. The Nurse immediately opened an ACCT
document with recommendations that he should be monitored all the
time until he was fully assessed by the mental health team.
34. The man was located for two nights in the segregation unit following
reception. At the time this provided the only place where he could be
constantly observed. On the evening of 5 February, he was assessed by
a Prison Doctor who provisionally assessed his suicidal ideas as being
related to a personality disorder rather than depression. As the general
practice surgery was closed at the time, the Prison Doctor telephoned
the man’s mother to confirm the dosage of his medication. He recorded
that the man was happy to continue taking his medication which he
found helpful. When questioned about his suicidal intentions, the man
acknowledged that, although he might kill himself, this would be a drastic
step as he had been expecting a longer sentence and was pleased to
have only 15 months to serve.
35. In accordance with the ACCT procedures, there was a multi-disciplinary
review of the man’s plan the following morning on 6 February. A
caremap and care plan was completed with actions which included
maintaining the constant observations, moving to the safer custody cell
on D wing, a gradual move to normal location, use of bereavement
counselling, and further assessment by the mental health in-reach team.
The ACCT review was signed by the suicide prevention co-ordinator and
the man.
36. A Registered Mental Nurse (RMN) saw the man following the review
and, with his agreement, further developed the care plan. This included
a referral to a counsellor for bereavement counselling, and consideration
of a move to share a cell with his brother-in-law. She recorded the
possibility that the man might be suffering post traumatic stress disorder,
which she discussed with the prison doctor. In line with the doctor’s
diagnosis, the RMN had seen no signs of mental illness nor thought
disorder.
37. The ACCT plan was reviewed again on 7 February. The man’s move to
D wing (the induction wing) safer custody cell was agreed that day, some
association time would take place with his brother-in-law prior to his
move to F wing, and plans were made for him to attend a family learning
and social and life skills course. Constant observations continued over
the weekend. The RMN recorded on 7 February that the man was
“much more alert and responsive” and he said he wanted to get better as
he had his children and partner to think of. He had also said that he had
no thoughts of suicide.
38. On 8 February, the man was seen by another RMN and offered the safer
custody programme. The man agreed to do this, although he is recorded
as saying that he “prefers to get a job”. It was agreed he could begin the
programme on 11 February unless he found a job he wanted. He said
that he felt more positive, was looking forward to seeing his family, and
thinking about the future.
39. The man’s ACCT was reviewed again on 11 February. It was confirmed
that most plans had been actioned, although assessment by the mental
health in-reach team needed to be followed up. The review agreed that,
considering the progress made, the ACCT observations could be
reduced to once hourly.
40. Also on 11 February, the man had his first counselling session with the
counsellor he had previously seen. The counsellor recorded that he was
positive and responsive, making a good start and wished to meet again.
He had discussed his family and children. The bereavement process
was looked at briefly, and the man described how finding his brothers’
bodies had made him feel their loss even more. Other records indicate
he was pleased to commence his counselling, was having supportive
contact from his partner, and was happy with his cell sharing
arrangements.
41. On 12 February, the man was formally assessed for the safer custody
programme by a member of staff from healthcare. He said that he was
happy to attend as soon as possible as it might be beneficial for him.
42. The ACCT record shows that the man was happy to have moved to
normal location on 15 February. He now shared a cell with his brother-
in-law. The same record indicates he had shown emotion when talking
about his brothers on 18 February. The second scheduled counselling
session with his counsellor on 18 February was recorded as a ‘failed
encounter’ due to the man being in a meeting and unable to attend. Two
days later, the man started education classes.
43. The ACCT was formally reviewed and closed on 21 February. The
review recorded that the man was in good spirits and seemed settled. He
had received a visit from his partner and mother and was in regular
contact with them. The review noted that he had commenced education
classes. The man said he had no intentions of suicide, and that he had
been initially shocked by his sentence as, after advice from his solicitor,
he had been expecting to go home. However, he had come to terms
with the sentence and was positive now.
44. On 25 February, the man was again scheduled to attend a counselling
session with his counsellor. This was also recorded as a ‘failed
encounter’, as he had gone to work and could not attend.
45. Late in the morning of 2 March, the man pressed his cell bell and an
officer attended. The man told the officer that he felt suicidal and did not
want to be left alone as he felt he could do something to harm himself.
The officer left the cell door open, and called for assistance. An ACCT
review was undertaken by an officer and attended by the Nurse that saw
him on reception. (This ACCT review was recorded in the man’s medical
notes, although there is no other record of it taking place.) It was noted
in his medical record that he was not getting on with his brother-in-law,
and intended to kill himself when his brother-in-law was asleep as he
wanted to be with his deceased brothers. It was agreed to place the
man back on constant watch, and he was moved to the healthcare unit
for the night.
46. The man was relocated the following day to D wing, where he was first
placed in a safer cell and subsequently in a shared cell. The D wing
observation book records between 3 March and 5 March that the man
was on an open ACCT, although there is no record of this being formally
reopened.
47. The Suicide Prevention Co-ordinator told the investigator that she and
another senior officer from D wing reviewed the man on 3 March when
he was back on D wing. She recalls that the man said he wanted to be
back on D1 wing as it was his ‘safe haven’. He made some reference to
being bullied by his brother-in-law. No bullying incident report was raised
on this occasion as the man had already been moved from F wing, and
the Suicide Prevention Co-ordinator considered that confronting his
brother-in-law might raise further problems.
48. The last CSRA, undertaken by the officer who carried out the initial
review of the man’s ACCT, on 3 March recommended that the man
return to normal location. He was happy to share with anybody, feeling
that he would get extra support from a suitable cell mate. The
management review booklet also undertaken at this time identified his
level of risk as medium. The next review for the CSRA was set for 2
April.
49. A member of staff from healthcare undertook a review of the man on 4
March. He found that he was no longer feeling suicidal, but was still
waiting for counselling. The member of staff amended his medication.
50. The D wing observation book records that the man started work as a
wing cleaner on 6 March. Because of his job, he decided not to start on
the safer custody programme. The RMN who offered the man the safer
custody programme recalled that she told the man he could begin the
programme whenever he wished, but that he was content having started
work.
51. On 10 March, a Community Psychiatric Nurse (CPN) from the mental
health in-reach team undertook a full mental health risk assessment.
She recorded the man’s previous history of suicide attempts and his level
of engagement with psychiatric services. She documented his care in
the community by his Doctor and the name of his CPN in the community
mental health team. Her care plan identified the need for bereavement
counselling and liaison with the community mental health team. Her
assessment also recorded the anniversaries of the deaths of the man’s
brothers as 15 December and 16 March, and she identified his
vulnerability around these dates.
52. A week later, on 17 March, the man’s cell mate caught him stealing an
ounce of tobacco and some hair gel from his cell. The cell mate told the
investigator that he had known the man for about a month and had
shared a cell with him for about a week. The man’s cell mate was also a
cleaner and was a trained Listener, although he did not act in that
capacity with the man. The cell mate said that the man told him that he
had stolen the items as he was being bullied.
53. The man also told the Suicide Prevention Co-ordinator that he had been
bullied. However, when questioned, the man was unable to identify any
individual. Consequently, a bullying incident report was not raised on
this occasion. The Suicide Prevention Co-ordinator told the investigator
she considered the man to have mixed well both with other cleaners and
with staff and, from her knowledge of him she thought he would have
been able to ask for help from staff if he was being bullied.
54. Action had to be taken following the theft. The Suicide Prevention Co-
ordinator explained to the investigator that it was decided not to place the
man on a disciplinary report because of his vulnerability. Additionally,
she took account that the man had lost his job, and decided that no
formal investigation need take place. Instead, it was decided to move
the man from D wing to C wing.
55. The Suicide Prevention Co-ordinator ensured that the ACCT was
formally reopened by an ACCT assessor on 17 March as the man had
been relocated from the more supportive environment of D wing to
normal location. Half hourly observations were started as he was
allocated a single cell.
56. The ACCT ongoing record shows an appropriate level of observations
and conversations took place with the man. On 19 March, a prison
officer had a fuller conversation with the man recalling his brothers whom
the officer had known in the past. No adverse reaction to this
conversation is recorded.
57. The next day, the man’s mother decided to tell him about the suicide of
one of his friends. She believed that it would be better for him to hear
the news from her rather than through the prison grapevine, and she
urged him to speak to staff about it. Following this telephone call she
telephoned the prison to ask staff to speak with the man as she was
concerned about his reaction to the news.
58. The man had by then been relocated to F wing, although it is not clear
why. A SO recorded in both the ACCT ongoing record and the C wing
observation book that he had had a lengthy discussion on 20 March with
the man regarding his mother’s call. The SO asked him how he felt as
his mother had expressed concerns about his low mood. The man said
he was ‘ok’ and was not thinking of harming himself.
59. The following day, having been given his lunch, the man told the SO that
he had taken his cell mate’s medication the night before in the hope he
would not wake up. He complained of feeling unwell and scared. The
SO alerted healthcare and a Nurse quickly came to the wing. She
recorded in the medical record that the man had explained he had taken
the medication after hearing his friend had committed suicide, but had
vomited afterwards. After consultation with the local poisons unit, the
man was transferred to hospital overnight for monitoring.
60. The man returned to Leeds on the evening of 21 March. Hospital tests
had shown that his blood levels were normal, and no further action was
required. The man was recorded in the ongoing ACCT record as saying
that he was ‘ok and just wants to get his head down’.
61. An SO undertook an ACCT review on 24 March. This review took place
with the man and an officer, but without any healthcare or mental health
staff in attendance. The SO recorded that the man said that he was
settling well on F wing and that he was ‘ok’. The man also said that he
would talk to staff if he had any problems. The SO closed the document,
and recorded this closure with a summary in the F wing observation book
and the wing history sheet, noting that ‘communications’ had also been
notified. The post-closure interview date was set for 31 March.
Events of 26 March and 27 March
62. The man was seen by staff during the day on 26 March. They noticed
nothing unusual about him. At 10.13 when he was locked in his cell, the
man pressed his cell alarm and an officer noticed his cell light was on.
She responded and asked the man what was the matter. He alleged that
his cell mate had assaulted and verbally abused him. He asked if he
could be moved out of that cell and placed with his brother-in-law, who
was also on F3 landing. The officer looked at his head briefly, but was
unable to see any marks.
63. The officer reported the allegation to a SO who, having confirmed that
the man’s cell mate was not in the cell as he was on a legal visit,
indicated he would investigate the matter later after other matters had
been dealt with. She completed the appropriate paperwork (incident
report, bullying incident report and history sheet).
64. The officer told the man that the allegations would have to be
investigated before any consideration was given to him moving cells.
She assured him that a Nurse would also examine him after medications
had been dispensed. She told the investigator that “he seemed quite
happy with that, and thanked me for it”, and she locked him back in his
cell. As far as she was aware, the man had neither requested a cell
move prior to this nor made any complaints about his cell mate.
65. Later that morning, shortly before 11.10am, another prisoner, went to the
man’s cell by accident. He saw the man hanging and went to the officer
to tell her. The officer immediately ran to the cell and saw that the man
was hanging from the window bars. She shouted for other staff to help,
opened the cell door, and immediately tried to cut him down.
66. Another officer was supervising medications at the treatment hatch. The
officer heard the shout from the officer that previously reported the man
concerns about bullying down the corridor and saw her entering the cell.
He immediately raised a coded alarm on the prison radio for emergency
assistance. He rushed to assist the officer free the man from the ligature
and place him on the floor. The Nurse that previously saw the man when
he reported he was being bullied came directly over from the treatment
hatch and commenced cardio-pulmonary resuscitation (CPR).
67. The wing SO arrived within a minute with an officer. The SO assisted
the Nurse with CPR until another Nurse arrived with other healthcare
staff shortly afterwards, took over at about 11.15am.
68. The locum doctor at Leeds also responded to the emergency call and
reached the cell at 11.18am. The nurses initially found no pulse, but
established some carotid pulse (in the artery supplying the head with
blood) after administering CPR. They applied the automated external
defibrillator (a machine that applies electrical impulses to the heart and
advises whether there is any rhythm which might be stimulated), but did
not find a shockable heart rhythm. The Doctor administered adrenaline
intravenously, and then found a stronger carotid pulse. CPR was
maintained by the second Nurse to arrive on the scene and the SO until
the paramedics arrived in the cell at 11.35am. The paramedics applied
mechanical ventilation to the man a few minutes later, and he was taken
to Leeds General Infirmary at about 11.56am, accompanied by prison
staff. It was recorded in his medical notes that he had cardiac output,
but was not breathing spontaneously when taken to hospital.
69. The Duty Governor instructed that the man’s cell mate be moved to the
segregation unit as she was unsure whether he had left the cell before
the man had harmed himself. (This follows another death at Leeds, in
which a prisoner had been implicated in the death of his cell mate; the
Duty Governor felt it necessary to preserve evidence in the first
instance). Once it became clear that the man had been seen alive and
well after his cell mate had left for his legal visit, the cell mate was
released from the segregation unit. The Duty Governor confirmed that
while he was in the segregation unit, the man’s cell mate was unaware of
his attempt to harm himself. The cell was secured at mid-day in order to
preserve evidence and allow the police to investigate.
70. A member of staff from the healthcare unit telephoned the man’s mother
and sister at about 12.15pm. She told them that the man had attempted
to hang himself and had been taken to LGI. She informed them that he
was still alive on leaving prison, and they said they would go to the
hospital. The member of staff gave them her telephone number should
they need to call her again.
71. Shortly before 2.15pm, the man was moved to the intensive care unit at
LGI, following scans and continuing emergency treatment. The member
of staff who contacted his mother telephoned the unit at 2.15pm and was
told that his mother and sister were with him. Medical staff were
considering a trial without ventilation to test if the man could breathe
independently. The member of healthcare staff had a further discussion
with the unit at 3.40pm. She was informed that the scan showed the
man might have severe brain damage.
72. The RMN who saw the man after his initial assessment in prison made
another telephone call to the unit at 7.30 pm. She was informed that the
scan showed severe brain damage, there had been no improvement
since the removal of sedation, and the man’s condition would be re-
assessed in the morning. The RMN was told that all the man’s family
were with him.
73. The bedwatch officer told my investigator that free access was given to
the family all night, and the family were with the man when his condition
deteriorated at about 4.50am.
74. At 5.00am on 27 March, the man died. After his death, the bedwatch
officer was given an official notification by a hospital doctor. He reported
the news to the prison and then left the hospital.
75. A ‘hot debrief’ was organised for staff on 26 March at about 12.20pm. It
was attended by all staff immediately involved. Staff recall that a ‘critical
incident debrief’ was organised some weeks later to provide additional
support to staff involved with the man. The meeting was run by a
member of the care team. All staff interviewed considered they had
sufficient support. The Duty Governor spoke with the brother-in-law, and
explained what had happened. An ACCT was opened for him as a
result.
76. The post-mortem report, dated 13 June and prepared by a Professor
noted that the man had complained of bullying and being clipped around
the ear to a prison officer after 10.00am, before being found hanging at
11.10 am. The Professor identified hypoxic brain damage as the
immediate cause of death, and this due to self-suspension by hanging.
He found no natural disease, and only the presence of normal
therapeutic drugs. He also found there were no other injuries to indicate
restraint or an attack by a third party.
77. Following the man’s death, the prison’s Family Liaison Officer visited the
mans’ mother’s house with the chaplain. The prison offered to cover the
cost of the funeral expenses. The man’s partner subsequently visited
the prison to visit his cell, and was accompanied by the Governor.
ISSUES
Family concerns
78. When the FLO and the original investigator met the man’s family on 19
May 2008, they were given a list of questions that the family wished to be
answered. Subsequently, the family’s solicitors provided the investigator
with statements from the man’s mother and partner raising further
issues. I hope that this report has addressed them as far as it can. I am
aware, however, that there are still some important issues that have yet
to be considered because of the unavailability of certain witnesses.
79. The family’s original questions were:
 Why was the man taken off ‘suicide watch’?
 Why was he moved five times in seven weeks?
 Is this normal to be moved so many times?
 Why was he put back on F wing when he did not want to be
there?
 For how long did staff give him CPR?
 Why did the member of staff from healthcare that contacted the
man’s mother tell them he was still breathing when it should
have been obvious his chances of survival were so low?
80. The ACCT review of 24 March is considered below. I hope the report
shows why the man was moved so many times in a short space of time.
Given that staff appear to have been acting in his interests on each
occasion, I am satisfied that the moves were appropriate (albeit it is not
normally considered desirable for prisoners to change cell locations so
many times in so short a period). However, it is not clear why the man
moved to F wing on 20 March, but he was seen by an SO within three
hours of his arrival there and did not express any concerns about it. I
hope that the Key Events section has answered any questions about the
treatment the man was given after being found on 26 March.
81. It is very unfortunate that the family feel that they were given false hope
during the initial telephone call. However, having reviewed the evidence,
I am satisfied that when the member of staff made the call the
information she had been given may well have led her to believe that the
man was alive. As such, I do not make a recommendation. The
Governor may wish to consider, however, how families are contacted in
such circumstances and what information they are given to avoid such
misunderstandings.
82. A further matter came to light following the submission of statements
from the family’s solicitors. This concerned a collection that had been
made by prisoners in respect of the man. The family have said that the
Prison’s Family Liaison Officer telephoned them and asked if they could
accept the money by cheque. As they did not have a bank account, they
asked if the money could be given as cash, and they say that the
Prison’s Family Liaison Officer agreed to deliver the money. However,
they say that he did not do so. Although the initial investigator tried to
speak to the Prison’s Family Liaison, he was unsuccessful. On
reviewing the first draft report, the second Assistant Ombudsman
assigned to this case noticed that this issue had not been addressed,
and that the Prison’s Family Liaison Officer had not been interviewed.
Although the Assistant Ombudsman has subsequently visited Leeds to
interview the Prison’s Family Liaison, unfortunately the officer was off
sick. In response to a previous version of this report, Leeds said that
there is no record to suggest that there was a collection, and that the
only money recorded within the finance office and given back to the
family was the money from the man’s account. Clearly, the versions of
the prison and the family conflict, and in the absence of any other
evidence, I am unable to resolve this matter. While not making a formal
recommendation, the Governor may wish to contact the man’s family
directly to see if there is any other way this matter can be resolved.
Sentencing
83. It would not be appropriate for the Ombudsman to discuss the merits of
the sentence given to the man on 5 February 2008, and I have not seen
the transcript of the judge’s comments. I have, however, seen the pre-
sentence report written by the man’s probation officer in which she
makes a clear case for him to be given a community sentence based on
the likelihood of his attempting suicide if sent to prison. The probation
officer then reinforced her opinion in a second report that was received
before sentencing, and her reports were faxed to Leeds after he was
sentenced. The man’s probation officer made every effort to bring her
concerns about the man’s welfare to the attention of the court and prison,
and I commend her for this.
Clinical care
84. As noted earlier, a clinical review was undertaken by a Doctor on behalf
of Leeds PCT. The clinical reviewer identifies some areas of good
practice. Specifically, he finds that an ACCT plan had been
appropriately opened on several occasions, including the use of constant
observations on two of those occasions. The Clinical Reviewer also
recognises the professional response of the prison team in resuscitating
the man both in March 2008 and in August 2007. I concur with these
conclusions.
85. However, the Clinical Reviewer has drawn a number of critical
conclusions in respect of the overall organisation of the man’s clinical
care. I agree with his conclusion that the man should have been
assessed and cared for by a consultant forensic psychiatrist. The man
clearly presented a known, and very high, risk of suicide. There had
been a community psychiatrist assessment diagnosing an ‘adjustment
disorder with prolonged grief reaction’. I judge that the man should have
been re-assessed by a psychiatrist within the prison. Whilst the
medication regime prescribed by the community psychiatrist was
maintained within HMP Leeds, this had not been reviewed by a
psychiatrist since the man’s imprisonment.
86. This initial failure was compounded by the lack of a follow up dynamic
mental health assessment and review. One action identified both by the
mental health in-reach team and within the man’s ACCT plan was
provision of bereavement counselling. However, the man only attended
one counselling session, with two further sessions recorded simply as
‘failed encounters’. Following these, on at least one occasion the man
was recorded as asking when his counselling was to recommence. It
appears there was no system in place to ensure that these problems with
the counselling sessions was reviewed either by a psychiatrist, the
mental health in-reach team, or as part of the ACCT review process.
87. Had there been assessment and review by a psychiatrist which, together
with co-ordinated input from the mental health in-reach team, informed a
robust multi-disciplinary ACCT review process, it might have been
possible to assess two further issues. First, as part of the ACCT ongoing
record, it was repeatedly recorded that the man asked to be taken off
ACCT. On one occasion, when making this request, he explicitly used
the language of his community psychiatric diagnosis of an ‘adjustment
disorder’, when he said “I can adjust now”. That this statement was not
considered thoroughly in a review is symptomatic of the lack of a mental
health perspective informing ACCT planning.
88. Secondly, there was no consideration of the potential use of cognitive
therapy (beyond bereavement counselling) to address, alongside
medication, either the already diagnosed ‘adjustment disorder’, or the
possibilities considered by healthcare staff following his reception that
the man was suffering post-traumatic stress or another personality
disorder. A full assessment by a psychiatrist could have prompted a
psychologist’s assessment of an appropriate course of cognitive therapy.
89. I agree also with the Clinical Reviewer’s conclusion that the man should
have been monitored under ACCT procedures on 24 March. The
Clinical Reviewer says that the clinical assessment on the man’s return
from hospital on 22 March after taking an overdose was unsatisfactory.
Whilst it is the case that the prison knew from LGI that blood tests had
proven negative, this was taken to suggest that the man had not taken
an overdose, and his claim that he had was not fully assessed.
90. In fact, the man was already on an ACCT at the time he had allegedly
taken an overdose and on his return to Leeds on the evening of Sunday
22 March. Given his history of vulnerability, and despite the difficulties to
the prison of his return on a Sunday evening, there should have been an
immediate review of his ACCT with consideration given to his location
either in the healthcare centre or in a safer custody cell, allowing for
further assessment.
91. A full review of the man’s ACCT was due the following week. This
review should have been informed by both clinical and mental health
assessments, particularly regarding his alleged overdose. In the event,
the review was informed by no such perspective.
92. The Clinical Reviewer concludes that, had the man been located in a
safer custody cell, this might have reduced the chance of him hanging
himself. I agree with this conclusion. The opportunity to use this option
was missed because of the failure to undertake an immediate review of
the ACCT on the man’s return from hospital, and the subsequent failure
to ensure a full assessment of his alleged overdose informed the full
ACCT review which was due.
93. I therefore make the following recommendations:
The Governor should liaise with the healthcare manager to
ensure that timely psychiatrist assessments are made of all
prisoners who have a substantial history of suicide attempts and
where there is a history of suicide within the prisoner’s family or
amongst friends.
The safer custody co-ordinator should liaise with the healthcare
manager to ensure a system is in place which monitors the take-
up of counselling identified in an ACCT plan, and that feedback is
provided as part of multi-disciplinary review of ACCT plans.
The Governor and safer custody co-ordinator should ensure that
an immediate ACCT review which considers safer locations is
undertaken on prisoners on an open ACCT on their return from a
hospital following an alleged suicide attempt.
ACCT plans, processes and the significance of anniversaries
94. I believe that both clinical and discipline staff at Leeds invested
considerable resources and time in supporting the man and that he
benefited from this during his time at Leeds. There are three ACCT
plans on record, one of them from his time on remand. Staff
appropriately opened an ACCT immediately upon his reception at Leeds.
95. The decision to close the first ACCT on the man’s transfer to F wing was
reasonable. However, instead of simply reviewing this closed ACCT
plan following the man’s transfer back to D wing after he disclosed
suicidal thoughts and feelings, a new ACCT plan should have been
commenced. Opening a new ACCT plan on 17 March on his transfer to
C wing was appropriate, particularly due to the circumstances of his
transfer. Given that the man returned from hospital only three days
earlier having said he had taken an overdose, the closure of the ACCT
on 24 March was, I believe, premature.
96. The investigator found two areas in which the quality of the ACCT plans
and processes could have been improved. First, mention has already
been made of the need for a more robust mental health perspective,
backed by a psychiatrist’s assessment, to have informed both the plans
themselves as well as review meetings. This was particularly so on the
man’s return from hospital on 22 March and the review undertaken two
days later.
97. Secondly, the initial plan from his reception on 5 February through to 21
February failed to identify adequately any ‘trigger points’. This failure
was carried through to the second plan opened on 17 March.
Specifically, both ACCT plans failed to record significant anniversaries.
It was known that the man was facing the difficult anniversary of the
death of one of his brothers in March, and this was made clear during his
interview with the SO who assessed his ACCT on 2 March. However,
the actual date was not recorded in the ACCT plan as a potential ‘trigger
point’, nor were any specific plans put in place to support and monitor the
man through this period.
98. In fact, the precise dates of both the man’s brothers’ suicides were
recorded by the CPN in her mental health assessment as 12 December
2006 and 16 March 2007. A further significant anniversary was
completely unknown to the prison. The anniversary of the man’s
brother’s funeral was March. This was the date on which the man was to
take his own life.
99. These significant anniversaries should have been explicitly recorded in
the ACCT plans as ‘trigger points’, allowing for specific support and
monitoring to be planned for the man. Had they been identified, the
man’s inadequately explained behaviour in stealing tobacco from his cell
mate on 17 March might have been better understood. Additionally,
knowledge of the date of his brother’s funeral would have informed a full
assessment of his actions when he allegedly took an overdose on the
weekend of 21 March, allowing for specific planning for 26 March.
100. PSO (Prison Service Order) 2700 on Suicide Prevention and Self Harm
Management refers to the need to identify ‘trigger points’, and plan
accordingly (in section 9.4 “Care-planning and general approach to
behaviour management”). These were not adequately identified in the
man’s ACCT at Leeds.
101. However, it is arguable that PSO 2700 does not adequately indicate the
necessity of identifying, recording and planning for ‘significant
anniversaries’ which may challenge prisoners with a history of suicide in
their family or amongst their friends. I make no formal recommendation
but draw this to the attention of the NOMS Safer Custody and Offender
Policy Group.
102. Whilst I take account that the Independent Monitoring Board at Leeds
has reported on the development of a significant dates diary, I make the
following recommendation:
The Governor should improve the quality of ACCT plans by
ensuring all documents identify and record ‘trigger points’ with
identified support plans for each, and that these must include the
recording of significant anniversaries
103. The man’s ACCT plan was closed by an SO who undertook its review on
the 24 March. The investigator found that this review was flawed, as it
was not multi-disciplinary and the CAREMAP action (to follow up when
the man would next have a meeting with the counsellor) had not been
completed. PSO 2700 specifically says, “the ACCT Plan can only be
closed once all the CAREMAP actions have been completed and the
Case Review Team judges that it is safe to do so” (Annex 8g). This
guidance was not followed.
104. The SO’s review with the man also failed to adequately take into account
that he had only days before allegedly taken an overdose, and returned
from hospital, which followed on from the suicide of his friend. There
was no mention of this in the review.
105. Unfortunately, the first investigator did not interview the SO who carried
out the review during the initial investigation. Subsequent attempts by
the second Assistant Ombudsman appointed to the case to speak to the
SO, either in person or on the telephone, have been unsuccessful. I
would have preferred to have given the SO the opportunity to respond to
these points before the publication of this report, but have been unable to
do so.
106. Given this, I have to make a judgement on the quality of the decision to
close the ACCT on 24 March based solely on the documentation. I
believe that the decision itself was flawed. Although the man had not
actually taken an overdose, the fact that he claimed that he had should
have been enough to have alerted staff that there might be ongoing
problems, and that further support was warranted. Furthermore, the
ACCT should not have been closed without the action on the CAREMAP
being completed. While it does appear from the ACCT that it might not
have needed to be opened in the first place (the man did not report
having any issues with losing his job and expressed no thoughts of
harming himself), there had been a change in circumstances which
should have been enough for the ACCT to have remained open.
107. I therefore recommend that:
The Governor at HMP Leeds should ensure the SO undertakes
further training in ACCT processes.
Bullying and violence reduction
108. There were three occasions when the man alleged that he was being
bullied. First, after disclosing suicidal thoughts and requesting a transfer
away from his brother-in-law on F wing, back to D wing. Secondly, to
explain his stealing tobacco on D wing. And, thirdly, within the hour
before hanging himself on F wing. The investigator found the responses
to these complaints were reasonable within the terms of the
requirements of PSO 2750 Violence Reduction Strategy.
109. On the first occasion, there is evidence that the man himself told staff
that he knew he might be able to achieve a move back to D wing by
disclosing some form of suicidal ideas. The Suicide Prevention Co-
ordinator made a clear decision not to pursue the man’s allegation of
bullying on the grounds that he was now safely on D wing and pursuing
the allegation might have worsened the levels of stress. Whatever
pressure the man may have been under from his brother-in-law at the
time remains unknown. However, on 26 March, the man made a request
to return to sharing a cell with his brother-in-law.
110. The man alleged bullying as the explanation for stealing tobacco from his
cell mate. The Suicide Prevention Co-ordinator questioned the man
regarding these allegations, and the man did not substantiate them by
identifying an individual responsible. She decided, therefore, that no
action could be taken. Due to his abuse of trust, however, the man was
relocated from D wing to C wing.
111. Again, due to concern regarding the levels of stress the man may have
been under, particularly as this relocation meant he also lost his job as a
cleaner, the Suicide Prevention Co-ordinator decided not to place the
man on a disciplinary report. I believe that this decision was entirely
proper, although it did mean the man was not held fully to account for his
action in stealing tobacco, and the explanation remained inadequate. As
identified above, the opportunity to question whether his theft was related
to the fact that it had been the anniversary of his brother’s suicide was
missed.
112. The man made his last allegation of bullying and of being assaulted by
his cell mate between 10.10am and 10.30am on 26 March. These
allegations were duly recorded by an officer, and were to be investigated
by a SO. This investigation did not take place. The investigator
examined the man’s cell mate’s cell sharing risk assessment. He had
been assessed as presenting a low risk in sharing a cell. No marks were
found on the man which were consistent with his having been assaulted.
113. The investigator found that the man had said, following his first attempt
at hanging himself at Leeds in August 2007, that he had deliberately
waited until his then cell mate was out of the cell at education classes.
114. I make no formal recommendation about this. However, I draw to the
attention of the Governor and the Safer Custody Co-ordinator that it
would have been useful to have highlighted within the ACCT document
that the man had previously attempted to hang himself when his cell
mate was out.
115. No substantial evidence that the man was subject to bullying was found
by this investigation.
CONCLUSION
116. The man had a history of making attempts on his own life, both in the
community and while on remand. Two of his brothers had committed
suicide, and the man had found them. Before he was sentenced, both
doctors and probation staff had warned that he would be at risk of
suicide should he be given a term of imprisonment.
117. When he returned to prison, he was immediately placed on an ACCT.
After appearing to settle, he was taken off the ACCT, but then stole
some tobacco from a fellow prisoner and the ACCT was reopened.
118. Two days later, the man told staff that he had taken an overdose of
medication. He was taken to hospital, but no evidence was found that he
had taken anything. He returned to Leeds, and on 24 March the ACCT
was closed. On 26 March, the man killed himself.
119. This investigation has found that the ACCT process could be improved at
Leeds. It has also found that there should be improvements in the
psychiatric services to prisoners who present a clear suicide risk.
RECOMMENDATIONS
1. The Governor should liaise with the healthcare manager to ensure that
timely psychiatrist assessments are made of all prisoners who have a
substantial history of suicide attempts and where there is a history of suicide
within the prisoner’s family or amongst friends.
Partially accepted: “The Governor will liaise with the healthcare manager and
the mental in-reach team manager to ensure that timely psychiatric
assessments are made of prisoners who have a substantial history of suicide
attempts and where there is a history of suicide within the prisoner’s family or
amongst friends”. (By May 2010)
2. The safer custody co-ordinator should liaise with the healthcare manager
to ensure a system is in place which monitors the take-up of counselling
identified in an ACCT plan, and that feedback is provided as part of multi-
disciplinary review of ACCT plans.
Accepted: “Safer Prisons PO to meet Health Care Manager to implement the
required healthcare monitoring system”. (By August 2010)
3. The Governor and safer custody co-ordinator should ensure that an
immediate ACCT review which considers safer locations is undertaken on
prisoners on an open ACCT on their return from a hospital following an
alleged suicide attempt.
Accepted: “A protocol to be written by 31/05/2010”.
4. The Governor should improve the quality of ACCT plans by ensuring all
documents identify and record ‘trigger points’ with identified support plans for
each, and that these must include the recording of significant anniversaries
Accepted: “ACCT reviews are now completed by dedicated team. A record of
significant dates is maintained. All available documents are now checked.”
5. The Governor at HMP Leeds should ensure that the SO that closed the
man’s ACCT undertakes further training in ACCT processes.
Accepted: “The SO will receive ACCT training by March 31st 2010”.