Individual at Holme House

Investigation into the circumstances surrounding the
death of a man at HMP & YOI Holme House
In March 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2011
This is the report of the investigation into the death of a man. He was 41
years old when he took his own life in HMP Holme House. I would like to offer
my sympathy to his family.
One of my family liaison officers contacted the man’s family to explain our role
and offer the opportunity for the family to be involved. The death of a family
member can be a difficult time, and this can be even more so when the death
occurs in prison. I hope my report answers any questions the family have. I
apologise for the delay in issuing the report, which is due in part to allegations
made in early 2010 which needed further investigation. The family liaison
officer and her colleague have been in regular contact with the family to
explain these delays. My investigator met with the man’s partner, her mother,
and her solicitor to discuss the draft report. I hope my report addresses the
issues upon which the family wanted clarification.
The investigation was undertaken by a senior investigator. We would like to
thank the Governor of Holme House and his staff for their co-operation. I
commissioned a review of the man’s clinical care whilst in custody, and this
was carried out by a clinical reviewer on behalf of the local Primary Care Trust
(PCT). I am grateful to him for his review and input into this investigation.
Whilst in HMP Kirklevington Grange, the man developed some problems with
his mental health over a fairly short timescale. On 17 February, a member of
the Independent Monitoring Board noticed that he seemed depressed and
expressed concern about his wellbeing. However, no additional support
procedures were put into place. During the early hours of 18 February, he
made a serious attempt to harm himself and required hospital treatment.
When he left hospital, he was transferred to HMP Holme House. He was
medically assessed when he arrived, and was placed in the prison’s
healthcare centre, supported under procedures for those thought to be at risk
of harming themselves. He remained in the healthcare centre until 8 March,
and was supported by these procedures until 19 March, when it was felt safe
for this extra support to be removed. However, after further concerns about
his mental health, he returned to the healthcare centre on 23 March. He was
not put back on special support measures. He was located in a cell with a
monitoring camera. This, however, was not because of concern that he might
harm himself, but so that mental health staff could monitor his behaviour
should they need to do so.
The clinical reviewer concludes that until the man returned to the prison’s
healthcare centre on 23 March 2009, he received treatment equivalent to that
which he would have in the community. He is unable to comment on the care
he received after that because of the lack of contemporaneous entries on the
medical record. The lack of medical information makes it similarly difficult for
me to comment on his wellbeing during this period. Staff did not identify any
major problems. He did, though, have trouble in receiving provisions he had
ordered, and a fellow prisoner thought that he was low in mood.
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I make ten recommendations following this investigation. My report considers
links with the families of prisoners who are at risk of harming themselves, as
well as making sure that staff, including healthcare, know how to put the
appropriate support procedures in place. The procedures should be reviewed
after they come to an end. I make additional recommendations about
obtaining community GP records (a recommendation the Ombudsman has
made to Holme House previously), safeguarding prisoners’ property, and
contact with the bereaved family. I am pleased to see that the National
Offender Management Service has accepted nine of my recommendations
and partially accepted the other.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Jane Webb
Acting Prisons and Probation Ombudsman April 2011
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CONTENTS
Summary
The Investigation Process
HMP & YOI Holme House
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was a 41 year old man, serving a prison sentence of four and a half
years. In December 2008, he was transferred to HMP Kirklevington Grange,
a category D prison (a prison with a lower level of security, for prisoners who
can be given a higher level of trust).
Whilst at Kirklevington Grange he began to suffer some problems with his
mental health, which was later found to be likely to have been caused by
cannabis use. On 17 February 2009, a member of the prison’s Independent
Monitoring Board became concerned that he appeared to be depressed.
They mentioned this to a member of staff, but no further action was taken that
day. During the early hours of 18 February, he cut his wrists seriously and
required hospitalisation.
Whilst in hospital, the man was placed on special support for prisoners at risk
of self-harm, known as ACCT (Assessment Care in Custody and Teamwork).
After being released from hospital, he was transferred to HMP Holme House,
a prison which has 24-hour healthcare cover. He arrived there on 20
February, and the ACCT support remained in place.
He was assessed on arrival and was located in the healthcare centre. He
was referred to a psychiatrist and given a full assessment the following week.
He continued to be supported by the ACCT procedures and, after seeming to
settle down, moved from the healthcare centre to ordinary location (a cell on a
wing) on 8 March. His ACCT support remained under review and, on 19
March, it was agreed that the ACCT procedures could be closed.
After initially seeming to settle on the wing, the psychiatrist saw the man on 23
March and had serious concerns. He was displaying signs of psychosis, and
the psychiatrist felt that he was presenting a risk of self-harm as well as a risk
of harm to others. He arranged for him to move back to the healthcare centre
for observation in a camera cell. He did not, however, open a new ACCT
document. Healthcare staff were not given instructions on the level of
observation he should be under via the camera in his cell.
The medical record does not contain information as to the level or type of care
the man received over the next four days. A post-closure review of his ACCT
should have been held, but this was not done. No problems seem to have
been reported, although his canteen provisions were delivered to his previous
location rather than to healthcare. On 27 March, staff noted that he went
about his daily business, interacting with both staff and prisoners, with no
apparent problems. He saw his mental health key worker, who noticed
nothing to indicate that there were any urgent concerns. A fellow prisoner,
however, thought that he appeared to be rather “down”.
After the prisoners had been locked into their cells that evening, staff in the
office noticed something they could not clearly make out on the camera
monitor screen. When they went to investigate, they found that he had
seriously wounded his neck, using glass from a broken coffee jar. Staff tried
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to save him while an ambulance was brought into the prison, and he was
taken to hospital. Sadly, emergency staff at the hospital were unable to revive
him.
I make ten recommendations. I repeat recommendations from previous
reports that when prisoners display signs of psychiatric problems, their
previous medical history should be obtained. There are further
recommendations about the opening and the operation of procedures
supporting prisoners thought to be at risk of harming themselves, prisoners’
property, use of camera cells, and contact with bereaved families.
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THE INVESTIGATION PROCESS
1. The investigation was formally opened at HMP Holme House on 1 April
2009 by my investigator. The Governor and his staff provided the man’s
core record and a number of other documents for examination. These
included copies of the CCTV footage of the man’s cell on 27 March
2009. The investigator met the Governor and representatives from both
the Prison Officers’ Association (POA) and Independent Monitoring
Board (IMB). He was shown around the prison, including the
houseblocks where the man lived, and the healthcare centre, including
his cell. He spoke to staff and prisoners who knew him.
2. Notices were issued to staff and prisoners informing them of the
investigation and inviting anyone with relevant information to contact my
investigator. The prison forwarded a letter from a prisoner about events
before the man’s death, and the investigator interviewed this prisoner.
He was given unrestricted access to the prison, staff, prisoners, and
documentation relating to the man. He also met the police sergeant in
charge of investigating the death on behalf of Cleveland Police.
3. Members of healthcare and prison staff, as well as one prisoner and a
former member of healthcare staff, were formally interviewed.
4. The local Primary Care Trust (PCT) commissioned a clinical reviewer to
conduct a clinical review of the man’s care and treatment. I would like to
thank him for doing so. The investigator discussed the report with the
clinical reviewer extensively throughout the investigation, and they
conducted joint interviews of staff at Holme House as well as jointly
interviewing a former member of healthcare staff.
5. Every effort is made to ensure that independent reviewers are appointed.
As an employee of a PCT, some of the clinical reviewer’s duties included
providing general practitioner services to HMP Durham, where the man
was initially remanded. He did not know the man. At one point early in
his sentence he was noted to have slightly raised blood pressure, and
was monitored by healthcare staff. When three subsequent readings
were shown to be normal, the results had to be seen by a doctor to
decide whether further monitoring was required. The clinical reviewer
was at the prison at the time and indicated that the readings presented to
him meant that the patient did not require further monitoring. This was
all done electronically and he did not meet him. This limited interaction
came to light some considerable way into my investigation. To appoint
another reviewer would have resulted in having to start the investigation
afresh, which would have meant a considerable further delay in providing
this report. I am satisfied as to the clinical reviewer’s independence, and
I hope that the man’s family agree.
6. A family liaison officer from my office contacted the man’s daughter to
explain our role and offer the opportunity to contribute to my
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investigation. The family liaison officer and investigator travelled to
Newcastle to meet the family, who asked the following questions:
• Were Kirklevington Grange and Holme House aware of his
previous medical history?
• Should he have been psychiatrically assessed whilst in hospital
after harming himself at Kirklevington Grange?
• Was he returned to prison from hospital too soon?
• Is taking medication monitored in Holme House?
• Was there any evidence that he gave away his belongings
before he took his own life?
• Should he have been on suicide and self-harm monitoring
procedures?
• The family had passed their concerns over his mental state onto
the prison. Were his mental health needs properly met?
• Were the family properly informed of his death?
The man’s partner also provided the investigator with a copy of a note
of her contacts with him, and the family’s impressions of how he
seemed to be.
7. My investigator wrote to HM Coroner to inform him of the nature and
scope of my investigation and to request a copy of the post mortem
report. Upon completion, my report will be sent to the Coroner to assist
his enquiries into the man’s death.
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HMP & YOI HOLME HOUSE
8. Holme House is a category B prison for unconvicted, convicted and
sentenced male adults. It opened in May 1992. The prison primarily
serves the communities of the Tees Valley, South West Durham, East
Durham and North Yorkshire. It has a total of six residential units,
known as houseblocks one to six. It has an operational capacity of
994.
9. The local PCT are the providers of healthcare services at Holme
House. There is an in-patient unit with 28 beds and 24-hour nursing
care. An out-of-hours doctor service is covered by the prison doctor
with help from an emergency out-of-hours doctor service.
Suicide and self harm monitoring
10. Assessment, Care in Custody and Teamwork (ACCT) is in place at
HMP Holme House to monitor and support prisoners assessed as at
risk of suicide or self harm. Once placed on ACCT, the prisoner is
observed at pre-determined intervals according to the perceived level
of risk.
11. Each prisoner is assessed within 24 hours and then reviewed at
intervals decided on an individual basis. The ACCT guidance says
that, to be effective, the review should involve the key people, forming
a case review team, who know the person at risk or are involved in
their care. The key questions for each review are listed as:
• have the problems that caused the ACCT plan to be
opened now been resolved?
• if not, what needs to be done to resolve them?
• have any further problems arisen that are now causing
distress and more risk?
• if so, what action can be taken to address these?
• is the person at risk now in contact with friends, family or
other support?
• does the person at risk now have something in their lives
that they feel good about?
• if not, how can this be improved?
12. Over time, the reviews should also consider other factors such as:
• distress – has anything changed to make the person at
risk more or less desperate?
• resources – has anything changed that makes the person
at risk now feel more or less alone?
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• previous suicidal behaviour – has anything changed that
makes suicide more familiar or more acceptable to the
person at risk?
• suicide intention or plan – has anything changed to show
that the person at risk is more or less prepared to kill
themselves?
• pattern of self harm – is self harm becoming more or less
frequent?
13. Amongst other things, the ACCT guidance states that prisoners should
be cared for in a safe environment and it is for the case review team to
decide the most appropriate place to locate an individual prisoner.
14. An ACCT document can be opened by any member of staff working in
the prison. An ACCT should be opened when anyone has any
concerns whatsoever that a prisoner may be at risk of harming him or
herself.
15. Once it has been agreed that an ACCT is no longer required, a post-
closure interview must be held. The date for the interview is a matter
for the case review team to decided, but it must be within seven days
of the closure of the ACCT document.
Camera cells
16. Seven cells in the healthcare centre at Holme House have CCTV
cameras in them. Images from the cells are relayed back to screens in
the healthcare office. These images are also recorded. Arrangements
for monitoring the screens are made on an individual basis.
Previous deaths in HMP Holme House
17. There had been 16 deaths of prisoners in Holme House prior to the
man’s. There have been two further deaths since. Previous reports
have included recommendations about obtaining prisoners’ medical
history, particularly where there are psychiatric problems. One
previous recommendation refers to use of the camera cells, although
this was in relation to prisoners thought to be at such risk of harm that
they were under constant observation by staff. The Ombudsman
previously recommended that all entries to medical records should
show the reason for the action, and in April 2010 the Prison Service
accepted a recommendation that the Head of Offender Health should
review record-keeping. The Ombudsman has previously
recommended that, in accordance with the ACCT guidance,
consideration should be given to involve a prisoner’s family in the
ACCT process.
Her Majesty’s Inspectorate of Prisons
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18. HM Chief Inspector of Prisons conducted an unannounced follow-up
inspection of Holme House in March 2009. Following the inspection,
she said that suicide and self-harm prevention work was of a high
quality, though there was little evidence of, or understanding shown
about, trigger points for self-harm. Mental health provision was
described as reasonable, although there were no day care services.
She recommended that the review of mental health services should
ensure that the deployment of mental health nurses is sufficient to
cover primary mental health needs.
Independent Monitoring Board (IMB)
19. Each prison in England and Wales has an Independent Monitoring
Board, which is made up of volunteers from the local community. The
Board is responsible for monitoring day-to-day life in the prison and to
ensure that proper standards of care and decency are maintained. The
2009 annual report published by the IMB for HMP Holme House does
not raise any issues relevant to this investigation.
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KEY EVENTS
20. The man was arrested on 14 July 2007, and subsequently charged with
grievous bodily harm. He was convicted on 15 October 2007, and
sentenced at Crown Court on 8 April 2008 to four years and six months
imprisonment. He was taken to HMP Durham. Papers from his
induction processes indicate that this was his first time in prison.
21. A health screening on the day he arrived in Durham showed that his
blood pressure was slightly high, but he was otherwise fit and well. He
said that he had never tried to harm himself.
22. On 12 May, he was transferred to HMP Acklington. His reception health
screening shows he reported that he occasionally suffered from high
blood pressure. He seemed to settle well at Acklington. He had various
minor contacts with healthcare for problems with his foot, ankle and
knee, and for pain in his ear.
23. After undertaking the relevant course, he was awarded a certificate in
Level 1 Drug Awareness. It was awarded on 13 August.
24. Having been assessed as fit for transfer, he moved to HMP Kirklevington
Grange, a low-security category D prison on 12 December 2008. His
reception health screening did not identify any problems. He saw the
prison doctor on 15 December about ear pain and, although unable to
hear in that ear at the time, he said that the pain was much improved and
the problem nearly resolved. He was prescribed co-codamol for pain
relief.
25. The man was awarded a certificate for completing a Safety Matters
course on 19 December. In January 2009, he failed a drugs test. He
was referred to the Counselling, Assessment, Referral, Advice and
Throughcare (CARAT) team, who provide support for prisoners who may
have drug problems. He said that he had shared a cigarette whilst at
Acklington which must have contained cannabis. He completed the
CARAT induction course on 8 January, and on 12 January started work
in the laundry. On 14 January, he was given a random drug test, which
was negative. On 23 January, he completed the next stage of the
CARAT programme, and another drug test was negative.
26. As part of his ongoing assessments, an Offender Assessment System
report was completed on him on 6 February. (The Offender Assessment
System, or OASys, is used to assess offenders’ likelihood of
reconviction, the factors associated with their offending and the risk of
harm they present, both to themselves or to others.) The assessment
noted that his emotional state at the time he committed his offence might
have meant that his actions were not inhibited as they normally would
be. Emotional stress might have caused him to act outside his normal
levels of behaviour.
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27. From about this time, there seemed to be a marked deterioration in the
man’s sense of his own wellbeing and his stability. According to the log
of contact provided by his partner, in contacts with her on 7 and 8
February, he said that he had been “taking stick” from prisoners and staff
for various things. In telephone calls on each of the three following days
he told his partner that he thought that people were listening in on his
telephone calls. He said that when he came off the telephone, people
were talking to him about things he had mentioned in the conversations.
During a visit on 15 February, he told his family that he was worried that
someone was out to get him. People were repeating information from
his telephone calls to him, and he thought that he had heard people
outside his cell talking in what could be perceived as veiled threats.
28. Having completed an alcohol awareness course on 16 February, he
telephoned his partner a number of times, and seemed to be very
anxious. He telephoned her again the following day and accused her of
being involved in the general conspiracy he felt was being formed
against him, though he later called back and apologised. (He later
admitted to his psychiatrist at Holme House that he smoked two
cannabis joints on 17 February.)
29. A member of the IMB spoke to the man on 17 February, and was
concerned that he seemed depressed. The IMB member asked a
member of probation staff to speak with him, but the person in question
did not get time to do so before finishing work that day.
30. During the morning of 18 February, at approximately 4.35am, a member
of staff patrolling the wing noticed some blood visible under the man’s
cell door. When the door was opened, staff found that he had cut his
wrists (the files are not clear as to whether he used a butter knife or the
handle of a razor) and was bleeding heavily. An ambulance was called
at 4.40am, as staff tried to stem the flow of blood. Paramedics arrived at
5.00am and took over from the staff providing first aid. The man,
accompanied by prison staff, was taken to hospital at 5.35am. His
condition was stabilised, and he was admitted as an in-patient.
31. When seen by the doctor, the man said that he had taken at least 13
paracetamol tablets, and had been asking other prisoners for more. The
doctor later confirmed that he did have that amount of paracetamol in his
system. He told one of his escorting officers that he had been visited by
another prisoner at 4.00am and told to go to the kitchen when his cell
was unlocked in the morning.
32. At 8.36am on 18 February, the man’s partner telephoned Kirklevington
Grange. She said that a prisoner who knew the family had contacted
them by telephone and said that the man had harmed himself. She
wanted to know if this was correct and, if so, what had happened. The
situation was explained to her and she was told that he had been
admitted to hospital.
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33. Having initially been taken to hospital, the man’s condition was
stabilised. He was then transferred to a general ward at another
hospital.
34. Whilst he was in hospital the ACCT procedures were put in place. He
himself expressed concern to the prison staff about his mental health.
35. Members of the man’s family visited him in hospital, and they told the
escorting staff that he said that he had been threatened by another
prisoner. He had been instructed by this prisoner to attend the kitchen
when prisoners were unlocked that morning, and they thought that he
might have harmed himself in order to avoid the situation.
36. The next day, 19 February, he was visited by his partner in hospital. She
thought that he was very paranoid. He believed that everyone was trying
to hurt him. When the nurses tried to take blood samples, he pulled the
needles out because he thought they were trying to inject him with
something. He thought that people had been hurting him in his sleep,
and tampering with his cigarettes. He was refusing pain relief
medication, and had been tearing his bandages. He told prison officers
that he thought that the room next door was being prepared as a place to
torture him.
37. Discharged from hospital on 20 February, he was transferred to Holme
House, a prison with 24-hour healthcare, instead of returning to
Kirklevington Grange. His partner spoke to a nursing Sister at the
hospital, and was told that the psychiatric team from the hospital had
been in contact with the prison medical team. They had agreed that he
would be assessed once he got to Holme House. An entry on his
medical record that day records that a telephone call was taken from the
family, expressing concern that he was being discharged from hospital
without a psychiatric assessment. They were assured that he would be
seen by the appropriate people. A note was made in the medical file that
he was going “to healthcare, for observation in a single cell with a
camera”. He was prescribed diazepam (an anti-anxiety medication).
38. On his arrival in Holme House, the man attended a review of his ACCT
support. The review was also attended by Prison Doctor A, Nurse A (a
mental health nurse), Senior Officer (SO) A, and a governor. During the
meeting, he made poor eye contact with the other attendees (poor eye
contact can be a symptom of psychosis), and expressed the wish that
everybody would leave him alone. He said he was glad that he had not
taken his own life, but had thought that he was going to be killed the next
day. He remained concerned that it could still happen.
39. The doctor did not think it likely that he would attempt to take his own life
again, but said that it would probably take some time before he would
feel safe at Holme House.
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40. As a new arrival at Holme House, a cell sharing risk assessment (CSRA)
was completed. This is an evaluation as to whether placing the prisoner
in a shared cell presents any risk to the other prisoner. The assessment
notes that the man expressed concerns about sharing a cell. The ACCT
was reviewed, and a note was entered onto the ACCT record “…to
remain h/care [healthcare] camera cell. For 15 min obs [observations]
and quality interactions and entries. No razors i/p [in possession]”.
41. His property needed to be brought across from Kirklevington Grange.
However, there was a delay receiving it and it was not available to him
for some time after his arrival in Holme House. The papers do not
indicate when his property was returned to him.
42. He was visited by his partner on 21 February, and she thought that he
remained very paranoid. He wanted to see pictures and copies of
documents with his name on them, as he thought his identity was being
erased from the outside world. He told her that the Governor had told
him that a nurse would talk to him later that day.
43. A note on the man’s medical file (entered the following day) shows that
he was seen by Nurse A for a mental health assessment on 21 February.
She described him as guarded, making poor eye contact and displaying
little emotion. Cutting his wrists appeared to be an impulsive action, and
he expressed regret at what he had done. However he would only give
vague reasons for why he had done this, saying that he had felt
paranoid, and other prisoners were repeating his telephone
conversations to him. He said he did not feel depressed at the time and
had no intention of harming himself again. She thought that, in view of
how he presented during their interview, she needed to discuss his care
with the mental health in-reach team (the prison’s mental health service).
She said that he should remain in healthcare until she had done so.
44. The man’s partner’s notes show that she telephoned the healthcare
centre on 22 February to enquire about him. A nurse told her that he
was “doing fine”. There is, however, no note of this conversation in his
medical record. She telephoned again the following day, and was told
that he had been assessed and a referral made for a psychiatric
evaluation.
45. An ACCT review was held on 24 February. The man said that he felt
that he had sorted his thoughts out, and had no further ideas about
harming himself. He wanted to return to Kirklevington Grange. The
review decided that the ACCT would remain open until he had been
seen by the mental health team.
46. He remained under observation in healthcare, with visits to the hospital
for his wounds to be checked and treated. There did not appear to be
any serious problems. Nurse B was assigned as his key mental health
worker at the prison. He had an appointment to see her on 26 February,
but it clashed with an outside hospital appointment so had to be
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rescheduled for the following day. In addition to their mental health
review meeting, she also attended his ACCT review on 27 February. In
the meetings he denied any current thoughts of self-harm and said that
he “felt bad” about what he had done. He knew about the support
available to him, including Listeners (prisoners trained by the
Samaritans), Samaritans, and talking to staff. He still acted in a
distracted manner, and said he wanted to return to Kirklevington Grange.
It was agreed that the ACCT would remain open.
47. The man remained in healthcare, where staff continued to keep him
under observation. On 1 March, he complained of toothache, and was
given paracetamol and added to the list to see the dentist. He was seen
throughout the week by various members of healthcare staff. In
telephone calls to his partner, he continually told her how sorry he was
for what he had done and the things he had said. He underwent an
initial assessment by the mental health team on 5 March, and was again
prescribed diazepam. He was also introduced to his new CARAT
worker.
48. The following day, 6 March, his ACCT was reviewed again. He came
across as polite and communicative, but appeared preoccupied at times
and his conversation continued to display elements of paranoia. He
denied any further intention of harming himself. It was agreed that the
ACCT would remain open, and that he would be assessed by a visiting
psychiatrist the following Monday to advise on his mental state and the
risks he presented. His ACCT would be reviewed the day afterwards.
49. The same day, the man was visited by members of his family. They
could see that his paranoia was still strongly evident. He expressed
suspicion as to why hospital staff wanted to see him, and did not believe
that the doctor who had seen him was a real doctor. He told his family
that he was due to see the psychiatrist the following Monday, and was
suspicious of this arrangement too. His ACCT was reviewed the same
day. Notes indicate that he appeared better than previously, and had no
signs of paranoia, indicating that he presented differently to staff and to
his family.
50. The man’s medical record for 6 and 7 March show that his electronic
record was accessed by Nurse C, but the notes do not indicate why.
She also made the next entry on his medical record, which was a note of
the review of his ACCT on 8 March. He told staff that he wanted to go
back onto a houseblock and “get back to normal”, so he could work
towards a transfer back to a category D prison. He said that he had no
more thoughts of wanting to harm himself, and would never do that
again. It was agreed that he should move back to a houseblock, and he
was aware of how to get support if he needed it. He seemed very
settled, and made good eye contact during the meeting. It was agreed
that the ACCT would remain open to support him through the move to a
houseblock.
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51. Having moved to houseblock four on 8 March, the man was reported to
be pleased at leaving healthcare and returning to normal location.
Houseblock four is the induction block, and he hoped to soon move to
houseblock five, which is a more settled environment.
52. A forensic psychiatrist held a review with the man the next day. The
doctor noted that he had probably been motivated to harm himself
because of psychosis induced by using cannabis. He admitted smoking
two cannabis joints the day before he cut his wrists. He said that he was
not now using cannabis. He expressed regret at his actions, seemed to
have no intent to harm himself again, and was generally able to
rationalise his feelings. Having discussed the case with his senior
consultant, the doctor concluded that the risk of him harming himself
again was low at that time. However the doctor noted that he was
prescribed a regular dose of diazepam (commonly used to treat anxiety)
this would be likely to mask the extent of his psychosis. The doctor
reduced the dosage, and his mental state and the risk he presented
would be monitored. A further psychiatric review would be held after two
weeks.
53. Also on 9 March, the man’s partner telephoned his outside probation
officer to tell her that the family were worried about his state of mind.
The following day his partner received a letter from him, accusing her of
having orchestrated the persecution he perceived himself to be suffering.
However, he telephoned her later that day, during which he appeared to
be happy.
54. His ACCT procedures remained in place, and a note on 11 March
indicates that he was getting on well with his cellmate. He did say,
however, that he had some concern about sharing a cell with someone
who was addicted to heroin.
55. Nurse B saw him on the houseblock on 11 March. He seemed guarded
and expressed paranoia, with little apparent insight into his symptoms.
He again expressed remorse for having harmed himself. He knew that
his partner had been in contact with the Probation Service, and was
under the impression that she had expressed some concern that he
might harm someone. He denied this, and denied any further intent to
harm himself. He also denied having any other symptoms of psychosis,
though the nurse noted that he appeared preoccupied at times. She
offered him advice on how to get help if he felt that he needed it.
56. Meanwhile, that same day, the man’s outside probation officer
telephoned his partner and said that she had spoken to nursing staff in
the prison. She was given reassurance that a care plan for him was in
place, and they were waiting for a psychiatric report. Later that day he
telephoned his partner. He said that the Probation Service had told the
prison about his partner’s worry that he was a potential threat to other
people.
17
57. Prison Doctor B considered the man’s prescription of diazepam on 12
March and reduced the dosage. An ACCT review was held, and a note
of the meeting shows that he wanted to put the self-harm incident behind
him. He exhibited no signs of paranoia, and seemed to be in good spirits
and settled. It was agreed that he would remain on the ACCT until the
psychiatrist’s report was available.
58. When his family visited him on 13 March, the man told them that he had
been diagnosed as psychotic and given medication. His family thought
that he seemed more settled, but still had moments of paranoia directed
at his partner. He said that he had applied for a transfer to Acklington.
Later that day he was told that he was being transferred to houseblock
five, which he appeared to be pleased about.
59. Initially he seemed to settle well on houseblock five. He said that he was
getting on well with his cellmate. When the investigator spoke to the
cellmate, he confirmed that there were no problems between them.
However, in a telephone call to his partner on 16 March, he appeared to
be depressed and agitated. In a further call two days later, he again
appeared paranoid and was argumentative. That same day, his partner
received a very disjointed letter from him.
60. The ACCT was reviewed on 19 March, at 2.20pm. The man said that he
had never self-harmed before, and realised that it had been a mistake.
He blamed drugs for making him paranoid. He was looking forwards,
was receiving visits from his family, and did not seem to have any
problems on the houseblock. He said that there were no problems
between him and his cellmate. As he had only been on the houseblock
for a few days, it was agreed that the ACCT would remain open.
61. Nurse B was not at the ACCT review. However, shortly after the meeting
finished, she visited the man on the houseblock. In the light of her
contact another ACCT review was held at 3.00pm, with the same
attendees as earlier, plus the nurse. He reiterated his regret at his
actions, and was aware of all the support mechanisms available to him.
The nurse was confident that the ACCT could now be closed, and all
present agreed that this should happen.
62. Prison Doctor B again reviewed the dosage of diazepam the man was
taking on 19 March and reduced the dosage further.
63. The man’s partner had another telephone conversation with him on 22
March. Once again, he appeared to her to be quite paranoid.
64. The forensic psychiatrist assessed the man on 23 March. The doctor
noted that he appeared psychotic and guarded. The man believed that
there was “something going on”, and he could prove this because
everyone knew what he was doing. He thought that his partner was
involved in the conspiracy, and said that she had virtually admitted it to
him on the telephone. He said that the relationship was over. He
18
thought that he was being monitored by the prison, and that someone
was going to “do [him] in”. He said that he had been indirectly
threatened, and people had told him that he would be harmed “in all
different kinds of ways: slashed, burned, acid”. He was not sure whether
his cellmate was involved. He denied having any intentions of harming
himself or anyone else.
65. The psychiatrist noted that the man “clearly has a significant history of
severe self-harm when psychotic”. The doctor felt that there was
significant risk of self-harm, and significant risk of harm to others. He
increased the medication and said that he should go back to the
healthcare centre. He should be reviewed after two weeks and, if there
was no improvement, he should be referred to a regional secure unit
(RSU’s accommodate mentally disordered offenders, whose level of risk
is too high to maintain them in general psychiatric services, but who do
not require to be placed in high security hospitals.) The psychiatrist
noted on the medical record that, if he deteriorated in the meantime, staff
should contact him and he would initiate referral to an RSU.
66. Later the same afternoon, the man was seen by Nurse A. The medical
record does not indicate what happened, but his care plan has a note
that he was back in healthcare due to concerns about psychosis. He
was to remain in a camera cell to be monitored, but there was said to be
“no current risk of self-harm”.
67. There is a note in the medical record of a telephone call from the man’s
sister. As he was in the healthcare centre, he did not have a personal
officer, so the call was taken by Nurse D. He had telephoned his mother,
to tell her that he loved her “in case anything happened to him”. The
family took this as an indication that he might harm himself. The nurse
gave an assurance that he would be kept under observation. The nurse
subsequently spoke to Officer A, and together they spoke to him. He
expressed no thoughts of wanting to harm himself, but did say that he
thought he had been moved to hospital for someone to “do him in”. The
nurse noted that he was in a camera cell, and she indicated that she
would make the night staff aware of what had happened.
68. The following day, a further entry was made on the man’s mental health
care plan. He was to remain in a camera cell in healthcare for
monitoring, although there was no indication of any current risk of self-
harm. There had been a telephone call from the Probation Service,
regarding anxieties that information about telephone calls from his family
was being fed back to him, which was fuelling his paranoia. It was
reiterated to him that the doctor was concerned about his wellbeing, and
that he was safe in healthcare. He made no eye contact with staff, but
conversed well with others during association and exercise. It was
agreed that he would continue to be kept under observation.
69. During the course of 24 March, the man saw his CARAT worker. He
also had a conversation with a member of the prison chaplaincy. The
19
chaplain commented that he was pleased to see the man without the
heavy bandaging on his arms. He told the chaplain that his self-harm
had been stupid, and he did not understand why he had done it.
70. The man’s partner wrote to him on 24 March about the difficulties they
had recently had in their relationship. The records do not make it clear
when he received this letter.
71. The man’s electronic medical record was accessed on 24, 25, 26 and 27
March, though it is not clear what the interactions were. His medical
record contained instructions in an entry of 26 March. They were that his
mood and behaviour should be monitored and treatments provided if
required. Staff were to ensure that he was coping with the normal
activities of daily living, and support provided as necessary. Records
show that he pressed his cell bell three times that day, and the calls were
answered by staff within one minute on two occasions, and within four
minutes on the other. The records do not show what the calls were
about.
72. A fellow prisoner in healthcare said that the man was very down on 26
March. His canteen supplies (personal provisions including such items
as tobacco) had been delivered to houseblock five, his previous location,
which left him short of some of the things he wanted. He asked staff if
they could be brought to him, but there had been a delay doing so.
73. A post-closure ACCT review was due to take place on 26 March. The
records do not show whether this happened.
74. The man went about his daily business through the course of the next
day. During breakfast, he approached Officer B and submitted
applications for a shower, exercise, association, and to use the
telephone. He also asked Officer C about his canteen, and asked if it
could be brought to him. The officer said that he would ensure that it
was brought across that day.
75. Some 30 minutes later, Officer B asked him if he required anything for
his shower. He asked for a razor (prisoners in healthcare are not
allowed to keep razors in their possession). The officer issued one, and
he returned it after using it. He again asked Officer C about his canteen,
and the officer said that it would be delivered that morning.
76. At approximately 10.00am, the prisoners were unlocked for exercise. At
interview Officer B said that the man appeared to be jovial. Both he and
Officer C noted that he spoke with staff and with other prisoners. After
exercise, his canteen had been delivered to the office, and Officer C took
it to his cell and asked him to check the contents. It contained cigarettes
rather than tobacco, so the officer returned to the office and confirmed
with the canteen that the man had ordered cigarettes. He then returned
the bag to him, removing the two razors, which were part of the pack, to
be stored in the office.
20
77. Later that morning he activated his cell bell once. Records show that it
was answered within a minute. (The electronic system only shows that
calls were made and answered. It does not indicate what the call was
about.)
Events of 27 March
78. Nurse B saw the man on the morning of 27 March. She asked about
paranoia or psychotic symptoms, which he denied, but she noted that he
was guarded and defensive. He said that he had no intent of harming
himself or anyone else. He was not happy at being back in healthcare
but was told that it was necessary, on the instructions of the psychiatrist.
She noted that she planned to see him again the following week.
79. During the lunch period Officer C spoke with him, and he told the officer
that he was fine. Separately, there was a disagreement between Officer
B and a prisoner. The prisoner became abusive, and was asked to
return to his cell.
80. At approximately 2.00pm the man was out of his cell on association (free
time for social activity), and mixing with other prisoners. He asked to use
the telephone, and made calls to his mother and daughter. Officer B
said at interview that, after the calls, he appeared to be in high spirits.
After association, he collected his evening meal. He spoke to Officer C
and told him that he was okay. He took his meal and went to his cell.
81. Both officers recalled that he seemed to be fine throughout the day, with
no indication that there was anything wrong or any cause for concern.
No other prisoners raised any concerns about him.
82. However, the prisoner said he noticed that the man seemed to be “down”
and “not himself”. As it approached the end of evening association,
when prisoners would be locked up for the night, the man approached
the prisoner and told him he was going. The prisoner asked if he was
moving, to which the man shook his hand, and said goodbye. He gave
the prisoner a bag of crisps (the only evidence of him giving anything
away). The prisoner said that he approached Officer B and told him that
he was concerned about him. He tried to go to the man’s cell but was
prevented from doing so. He told the investigator that he pressed his cell
bell three times, but the calls were unanswered. (Holme House records
indicate that the prisoner did not ring his cell bell at the times he said he
had.)
83. Prisoners in the healthcare centre were locked into their cells at
approximately 4.30pm.
84. CCTV footage of the man’s cell from the camera at approximately
7.00pm shows dark patches, of what is later shown to be blood, around
21
the cell floor. He can be seen occasionally moving around the cell and
lying on his bed.
85. Prison Doctor C was in the office in the healthcare centre at
approximately 7.10pm, and noticed from the monitor on the man’s cell
that it looked untidy. She asked Nurse D where the man was, and the
nurse pointed out that he was curled up on his bed.
86. At approximately 7.30pm, Nurse E and a Team Support Worker were in
the healthcare office watching the monitors in the camera cells. The
nurse noticed that the man was lying on his bed, but moving around
quite a lot. She mentioned this, then noticed that he was lying on the
floor with his back to the camera, between the door and the wall. She
pointed this out to the Team Support Worker, who then noticed dark
patches on the floor of the cell. The lights in the cell were off, so the
picture was dim, and so they went to the cell to investigate further.
87. The clock on the CCTV footage indicates that the cell lights were
switched on at 7.28pm. However, the clock on the CCTV is set
manually, and the time could be a few minutes out. From speaking to
staff and from the times mentioned in staff statements, it is probable that
the time was approximately 7.33pm.
88. The nurse looked through the observation panel in the door, and saw
blood spraying up the walls. The man was bleeding heavily. She called
to the Team Support Worker to initiate a Code Red (an emergency call
sign, indicating a prisoner suffering from blood loss). Nursing staff do not
carry cell keys, so the Team Support Worker ran back to the office and
Nurse F activated the alarm.
89. A number of staff reacted to the alarm, both discipline and healthcare,
the first staff arrived within seconds. The CCTV footage shows just over
a minute from the cell light being switched on to the cell door being
opened by a member of the discipline staff. Nursing staff brought
emergency medical equipment.
90. The man was on his knees by the sink, and bleeding from a wound to his
neck (the wound was subsequently found to have been caused by glass
from a broken coffee jar.) There was a lot of blood on the cell walls and
floor, and it was clear that it was a serious injury. Nurse F told Principal
Officer (PO) A to summon an emergency ambulance. Prison Doctor C
said that they would need a fast response paramedic too. He radioed
the request through to the communications office, and an ambulance
was called at 7.35pm. Officer D went to the gates at the end of the
hospital wing so ambulance staff would be able to access the healthcare
centre immediately they arrived. The PO went to the office to arrange for
staff to accompany the man to hospital.
91. The man was moving and was now lying on his left side, by the cell toilet.
Some of the nurses and SO A were in the cell. Nursing staff tried to
22
administer first aid, but he was reluctant to accept help and fended them
off, worsening his wound, telling staff to leave him alone. Nurse D talked
to him, trying to calm him down, whilst attempting to assess his injuries
and stem the blood. SO A held his hands away from the wound, and the
nurse used a towel to put pressure on it to stem the flow. All the while
she continued talking to him. They turned him onto his back to allow
them to apply a heart monitor, assess his pulse and breathing, and to
manage his airways to ensure he was breathing. They cut away his
upper clothing, when the full extent of the wound became apparent.
92. The doctor and Nurse G attempted to insert a tube into one of the man’s
veins, to allow medication directly into his system. They tried to find a
vein in several different parts of his body, but the extent of his blood loss
meant that they were unable to do so.
93. His condition was deteriorating rapidly, and he stopped breathing. Nurse
D and Nurse H began to perform cardiopulmonary resuscitation (CPR).
Nurse D managed his breathing, using a piece of equipment called an
ambu-bag to enforce breathing, whilst Nurse H performed chest
compressions. After approximately one minute, he began breathing
again. Once again he became hostile and tried to stop the doctor and
the nurses from treating him. He had to be restrained from fighting them
off. The amount of blood he had lost made it difficult to find a pulse, and
once again he stopped breathing. The nurses again performed CPR.
Chest pads showed that he still had a heart beat, and was still making
efforts to breathe.
94. The first response paramedic arrived at approximately 7.41pm. Because
of restricted space, Nurse F left the cell. The paramedic tried to access
his vein, but was also unable to do so. The CPR was stopped to allow
the paramedic to assess the man’s condition. He had no pulse, and had
again stopped breathing. Nurse D inserted a guedel airway (to keep the
airway open). The heart monitor was showing signs of activity, but
Nurse D, the doctor and the paramedic agreed that he was in a state of
Pulseless Electrical Activity (PEA is when the heart is showing action but
not producing a pulse.) The pupils of his eyes were fixed and dilated.
The nurses and the paramedic continued to carry out CPR until the
ambulance paramedic crew arrived at 7.54pm.
95. Nursing staff and paramedics moved the man on to the ambulance
trolley and took him into the ambulance. This was at approximately
8.20pm. Nurse D continued to assist the paramedics perform CPR
whilst they moved him, and SO A carried the oxygen bottle alongside.
96. The ambulance left the prison at approximately 8.28pm. Two officers
went with the man. Paramedic staff worked to revive him all the way to
the hospital. Although the hospital is slightly nearer to Holme House,
because of the nature of his injuries and the availability of a wider range
of specialists, he was taken to the Accident and Emergency section of
another hospital. Further attempts at resuscitation were made but sadly
23
were unsuccessful. His death was pronounced at 8.46pm. One officer
informed the prison by telephone at 8.50pm.
97. The duty governor had come back into the prison. Once the man had
been taken to hospital, some members of staff were visibly upset. The
governor ensured that members of the staff care team spoke to those
who had been involved. He also ensured that staff spoke to the
prisoners in the neighbouring cells to ensure that they were supported if
necessary. An officer was appointed as family liaison officer (FLO).
98. The governor chaired a hot debrief at 10.00pm. (Hot debriefs are held
as soon as possible on the same day of a death in custody to ensure that
staff have an opportunity to discuss any issues arising.) No specific
issues were raised, but staff were reminded that support was available
should they require it. A colleague telephoned Nurse B at home, letting
her know what had happened. She said that support was made
available to her.
99. The FLO identified the man’s elder children as his next of kin, and at
11.45pm she and police went to their address. She spoke to them and
told them of their father’s death.
100. The following day, all the prisoners in the healthcare centre who were on
open ACCTs were reviewed in case the death had a detrimental effect
on their wellbeing. The governor also informed the duty governor at
Kirklevington Grange what had happened.
101. Over the following days there were a number of contacts between the
prison and the man’s family. The role of family liaison officer was re-
allocated from the original officer to another, with additional support.
There were some occasions when the family were unable to contact staff
at the prison. This resulted in some confusion about arranging for his
belongings to be returned to the family, which caused additional distress.
In contacts with different people from the prison, the family were
sometimes given information which they felt conflicted with what they
had already received, which added to their anxieties
102. As is suggested in Prison Service Orders, the prison offered to contribute
to the costs of the funeral. They were represented at the funeral service.
Subsequent information
103. In January 2010, the investigator was made aware of a security report
which had just been made. A prisoner who had been in the healthcare
centre at Holme House at the time, had said that the man was being
bullied by two other prisoners. It was alleged that this may have had
some bearing on his decision to take his life.
104. The investigator contacted Cleveland Police, who investigated the
claim. They uncovered no other evidence to support the allegation,
24
and no further police action was taken. There had been no intelligence
in the prison at the time to suggest that he was being bullied, and the
investigator did not find any other evidence to suggest that this had
been the case.
25
ISSUES
The man’s previous mental health
105. The man’s family told my investigator that prior to his imprisonment, he
had sought help from his doctor for bouts of depression. They asked
whether Kirklevington Grange and Holme House would have been
aware of his previous medical history.
106. On reception, prisoners undergo routine reception medical screening.
They are asked about any current and previous medical issues, and
assessed by the member of medical staff carrying out the screening. If
the responses and the prisoner’s demeanour give no cause for
concern, prisoners’ GP records are not routinely requested. The man’s
family said that he was a private man who would have been unlikely to
share such information voluntarily. There were no indications of mental
health problems when he was given an initial medical assessment on
his reception into prison. He subsequently told the psychiatrist in
Holme House that he had seen his doctor about depression. He had
not, however, taken the medication as he did not think that he was
depressed. He only sought treatment because he had been advised
by his solicitor that it would be “helpful”.
107. When discussing this issue, the clinical reviewer told my investigator
that there is no established rule about contacting outside doctors for
information. It is at the discretion of healthcare staff at the individual
prisons. He said that, as the man had not given a history of mental
health problems, it is not unreasonable that neither Kirklevington nor
Holme House contacted his doctor.
108. In conclusion, he did not appear to give cause for concern until he
harmed himself at Kirklevington Grange, so his medical history would
not have been available until then. However, from this point on,
although not a requirement, I would have expected the medical team
looking after him to have contacted his doctor to obtain any relevant
background. Prison Service Order (PSO) 3050, Continuity of
Healthcare for Prisoners, states in paragraph 5.24 that receiving a new
prisoner “is equivalent to registering with a new NHS primary care
practice”. The PSO goes on to say
“5.25 Whilst reception screening in primary care is not
standardised it is expected that during the consultation the
health care team ‘make such enquiries and undertake such
examinations as appear to be appropriate in all the
circumstances’ as set out in the General Medical Service
contract. “
“5.26 Taking into account the morbidity in the prison population
it will be appropriate, in addition to general medical issues, to
specifically note;
26
• mental health
• substance misuse
• potential for self-harm”.
109. Previous reports from my office contain recommendations about
obtaining prisoners’ medical history, particularly where there may be
psychiatric issues, and I repeat them here.
The Head of Healthcare should consider ways of ensuring that
when prisoners display signs of psychiatric problems, their
community doctor is contacted to obtain any relevant medical
history.
Care at HMP Kirklevington Grange
110. After his initial stay in Durham, the man moved to HMP Acklington,
where he seemed to be quite settled. There were no indications of any
mental health problems. He moved again, this time to HMP
Kirklevington Grange, on 12 December 2008. This was a progressive
move to a lower security prison, and again no mental health concerns
were raised in the reception medical assessments. However, it seems
to be from this point onwards that his mental health began to
deteriorate.
111. Initially, he seemed to settle well at Kirklevington Grange. He engaged
with the CARAT team, which was seen to be going well. Reports from
the manager of the cleaning party were positive. Staff saw him as a
mature man who would benefit from the regime.
112. He later told staff that he had smoked cannabis at Acklington, which
appears to have been the cause of him developing psychosis. After
arriving at Kirklevington, he began to display an increasing sense of
paranoia. His family noticed this, but he appeared to have kept it
hidden from staff. The clinical reviewer told the investigator that
nothing in the clinical records suggests that the seriousness of his
problems could have been detected, and therefore treated, earlier.
113. Symptoms of his paranoia included a belief that the content of his
telephone calls was being repeated back to him. The investigator
raised this with the Governor at Kirklevington Grange, and also spoke
with the Safer Custody Manager. Although telephone calls across the
prison estate are routinely recorded for security purposes, they are not
listened to unless there is a reason to do so.
114. His calls were not subject to monitoring whilst at Kirklevington Grange,
and staff would not therefore have had access to information in his
calls. It cannot be ruled out, though, that other prisoners might have
overheard conversations. If the telephone booth door was not properly
closed, or he raised his voice, it is possible that he may have been
27
overheard. The family told the investigator that, when the man was in
hospital, one of the bedwatch officers said that after the man had
harmed himself, the officer had asked around the wing and been told
that “there was a wind-up going on”. Although the man subsequently
said that he felt that he was being victimised, the prison had no
evidence of or complaints about any bullying taking place.
115. A member of the Independent Monitoring Board saw the man on 17
February and was concerned about him as he appeared to be
depressed. The IMB member asked a member of probation staff to
speak to the man, but he did not manage to do so before leaving the
establishment for the evening. Neither of them opened the ACCT
procedures even though they are allowed to do so. I understand that
both were subject to internal disciplinary action. The probation officer
has since received ACCT training.
116. It was in the early hours of 18 February that the man made a serious
attempt to harm himself. He later said that he had been visited by
another prisoner at 4.00am and told to report to the kitchen when
unlocked. Cutting his wrists may have been an attempt to avoid having
to do so.
117. As Kirklevington Grange is a low-security prison, my investigator asked
for clarification of prisoners’ freedom of movement during the night.
Although cell doors have privacy locks which allow them to leave their
cells at night, they cannot leave their landings. Moreover, the landings
are quiet during the night and staff are able to hear when doors are
opened. Staff on duty on the man’s landing during the early morning
hours of 18 February said that they did not hear any doors opening, nor
had they seen any prisoners on the landing whilst carrying out their
patrols.
118. When he later told his family that he had been threatened by another
prisoner during the night, he gave a name and the offence the prisoner
had been convicted of. As part of Kirklevington Grange’s investigation
into what happened, the prison’s anti-bullying co-ordinator checked all
prisoners with the surname given and found none. He checked all
prisoners with the forename given, and found four. None of these were
in prison for the offence he had mentioned, and none of them were on
his landing so would therefore not have had access to go to his room
during the night.
119. When he was found to be heavily bleeding, there was an immediate
response by staff. He was given medical treatment, and successfully
transferred to hospital. I believe that the staff involved showed a high
level of care and professionalism.
120. Later that morning, his family received a telephone call from another
prisoner, informing them what had happened. The investigator asked
Kirklevington Grange why the family only heard about this from another
28
source. The prison does have a policy about informing prisoners’
families of a serious incident requiring hospitalisation. The prison tell
me that staff at the time were attending to him, and would have made
contact with the family at the earliest opportunity. They regret that the
family found out that he was in hospital in the way that they did.
121. Kirklevington Grange have conducted a review of what had happened.
After the man had been taken to hospital, a check was made on his
telephone calls from the previous night. He had made a number of
calls and in some appeared to be making reference to doing
“something” that night, although without any indication of what that
might be. Other prisoners later said that they thought he had been
acting strangely, and had been asking for rope or tablets from
prisoners. He said that people were laughing at him and whistling
songs which he took to be references to his partner.
122. The review also raised concerns over the man’s contact with the IMB
member the day before he had cut his wrists, when no ACCT was
opened despite concerns at his mental state. A security report
recommended that IMB members must be aware that if they have
concerns over a prisoner they must inform operational staff. The
concern might need to be reflected in the wing observation book, or an
ACCT might be required.
123. In the latest report on Kirklevington Grange, from March 2009, Her
Majesty’s Chief Inspector of Prisons said that there was little evidence
of bullying. There was an up-to-date anti-bullying strategy, and staff
appeared to be vigilant about bullying. The Chief Inspector also
commented that the circumstances of the man’s self-harming were
investigated promptly and thoroughly.
124. In the circumstances, I believe that he received appropriate care whilst
at Kirklevington Grange. Although his family recognised some
developing problems, he seems to have hidden them from staff. There
does not appear to have been any more that Kirklevington Grange
could have done to prevent what happened. The prison is aware that
the circumstances in which his family found out about him being in
hospital were not the best and have expressed their regret.
Discussions in the prison have since considered how this might be
avoided in future.
Assessment, Care in Custody and Teamwork
125. An ACCT was opened on the man whilst he was in hospital. It
remained open when he returned to prison on 20 February. On arrival
he was assessed, and housed in the healthcare centre. Although he
was in a camera cell, the observations specified by the ACCT
document were to be personal interactions, not observations via the
cameras.
29
126. The forensic psychologist held a review with the man on 9 March. It
was a thorough examination and, after discussing the case with his
senior consultant, the psychiatrist changed his medication. He also
asked for checks to confirm that he was not using cannabis (he
admitted cannabis use prior to his self-harming at Kirklevington.) The
psychiatrist concluded that the psychosis was induced by cannabis
use, and said he would review him again after two weeks. The risk of
harm to himself or to others was judged to be low, and he was
prescribed medication. It seems reasonable that he should have been
located in a prison with healthcare cover, rather than a hospital at this
stage.
127. The ACCT document was closed after a second review on 19 March.
The man had moved to normal location, consistently expressed regret
at harming himself, said that he was aware of the support available,
was in contact with his family, and remained in touch with the mental
health team. The most recent contact with his psychiatrist had
concluded that the risk of harm was low. On the face of it, it appears
reasonable that the ACCT should be closed at this stage.
128. However, during this time his family continued to be concerned about
his behaviour. Various family members contacted the prison on
several occasions to express these concerns. Guidance on the
operation of ACCTs is contained in Prison Service Order (PSO) 2700.
The PSO recommends that Governors appoint Family Contact Officers,
and that these officers should “encourage the involvement of
supportive family members in the care of at-risk prisoners”. The PSO
also recommends that “every effort should continue to be made to
include in the case review all those who can support the prisoner,
including where appropriate, family.” There does not seem to have
been any attempt to involve his family in his ACCT support, despite
their obvious concern. A previous report to Holme House from my
office has recommended that efforts to involve the family should be
made, and I repeat the recommendation.
The Governor should consider how to involve a prisoner’s family
in the ACCT procedures in accordance with the guidance.
Opening the ACCT procedures
129. The forensic psychologist made a further assessment of the man on 23
March. He found that he was psychotic and paranoid, fearing that he
was going to be harmed in some way. This is how he said he felt
before he harmed himself at Kirklevington Grange. The doctor noted
that he “clearly has a significant history of severe self-harm when
psychotic”, and felt that there was significant risk of self-harm, as well
as harm to others including his cellmate. His medication was
increased, he was to be moved to the healthcare centre, and
consideration would be given to a possible move to a regional secure
unit at the next review if he did not respond to the medication.
30
130. Nurse B, who was the man’s mental health key worker, told the
investigator that she had a full discussion with the psychiatrist in the
light of his assessment. One of the decisions made was to return him
to healthcare for observation for signs of psychosis. It was her
understanding of the conversation that there were no concerns about
him harming himself. Having had what she regarded as a full
conversation with the psychiatrist, she did not consider it necessary to
read his medical record when she saw him four days later on 27
March. He gave her no reason to be concerned that he might harm
himself.
131. I find it alarming that the ACCT procedures were not opened despite
this serious assessment and the steps which were to be taken as a
consequence. The psychiatrist said that he was aware of the ACCT
process but has not had any training in the system. However, despite
him not opening an ACCT, a full entry was made on the man’s medical
record which should have been followed up by the healthcare team
who made entries afterwards.
132. I note that the minutes of the Safer Custody Team Forum held on 9
September 2008 mention a shortage of ACCT assessors in healthcare.
The man’s medical record was accessed on 24, 25, 26 and 27 March,
but at no point does it seem that an ACCT was considered. It is my
view that he should have been subject to the ACCT support
procedures as a result of the psychiatrist’s assessment.
The Governor should ensure that all visiting staff dealing with
prisoners are aware of the ACCT process and how to initiate an
ACCT.
The Head of Healthcare should ensure that warning signs on
medical records of the potential for self-harm lead to
consideration as to whether an ACCT should be opened.
133. A post-closure ACCT review was due to take place on 26 March. The
records do not show whether this did in fact happen. There is no way
of knowing whether a review, if held, would have identified anything in
the man’s demeanour which would have led to a change in the level of
support he was receiving. He had hidden his feelings from staff in the
past, and those dealing with him on 27 March did not notice anything
which gave cause for concern. Nevertheless, the review should have
been held as scheduled, and adequate notes made.
The Governor should ensure that post-closure ACCT reviews are
held, in accordance with the ACCT guidance.
134. While in healthcare, the man was in a camera cell. This leads to the
natural assumption that he needed to be monitored. Whilst he was on
an ACCT he was indeed monitored, but this would be through personal
31
observations, separate from the camera images on the screen in the
healthcare office. When he was in a camera cell after his ACCT was
closed, it was so he could be monitored for any signs or development
of his psychosis. It was also so that CCTV footage would be available
to mental health workers looking retrospectively for signs of psychosis.
135. When his mental health key worker and his psychiatrist agreed that he
should go to healthcare in a camera cell, there were no instructions
given as to what level of observation was expected from the staff.
Holme House did have a policy on the usage of camera cells as safer
cells (designed to provide a safer environment for prisoners at risk of
harming themselves), which was drawn up in 2006. However, the
governor told the investigator that, by the time the man was in Holme
House, the cells in healthcare were no longer used as “safer cells”
(cells specifically adapted for holding prisoners thought to be at risk of
self-harm) so the policy was not being applied.
136. Whilst I do not think that it contributed to his death, I am concerned at
the confusion amongst staff regarding the level of monitoring that was
expected. I am also concerned that it produced a false sense of
security that he was being monitored, when there may well have been
comparatively lengthy periods when he was not. I am also concerned
that putting a prisoner, who was psychotic and believed that people
were watching him, in a camera cell may well have aggravated his
distress.
137. CCTV footage from his cell on the evening of 27 March appears to
show dark areas on the floor for some time before staff went to the cell.
When the cell lights are switched on, this can be seen to be blood. But
as he was not on an ACCT, and staff had no instructions to monitor
him, the fact that they did notice something wrong via the screens was
just chance. It was this chance that enabled the lengthy first aid that
he received. I do not feel that any criticism can be levelled at staff
monitoring the screens on 27 March, because they were not under any
instruction to keep him under observation.
138. I am pleased to see that a new policy was introduced in Holme House
in January 2010, which gives clear guidance on the use of camera
cells. The policy makes it plain that where a prisoner is in a camera
cell on healthcare, the monitor is never left unobserved. I am pleased
to see that the prison have reacted to concerns about the use of
camera cells, and I recommend that the Head of Healthcare keeps this
policy under review to ensure that it is effective.
The Head of Healthcare should review the camera cell policy at
regular intervals to ensure that it is being adhered to.
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Canteen provisions
139. There were problems with the man receiving his canteen provisions
when he moved from the houseblock back to the healthcare centre.
This meant that he did not receive, amongst other things, his tobacco.
There is some medical evidence to suggest that nicotine withdrawal in
a mentally unwell person can exacerbate their condition. However,
when other prisoners and staff found that he had not received his
canteen, they provided him with cigarettes, so he was not totally
without tobacco.
140. It is not possible to say whether the loss of his canteen had an effect
on his mental health. It does not, though, point to a good level of care.
Even if it did not affect his mental health, it did cause him agitation.
This was after he had faced delays in receiving his property from
Kirklevington Grange when he first arrived at Holme House. Prisoners
should not be deprived of their property. The Governor will wish to
satisfy himself that problems with prisoners’ possessions are
addressed promptly.
The Governor should consider whether systems to ensure that
property travels with prisoners when they move location are
adequate.
Access to razors
141. When the man took his own life, he was no longer being supported by
the ACCT procedures. Being in healthcare meant that he was not
allowed to retain razors in his own possession. This is a policy in the
healthcare centre, due to the number of prisoners who may harm
themselves. The fact that he was not allowed razors was not a
decision taken in relation to his own circumstances, but because of
where he was located.
142. Sadly, if a prisoner wishes to harm himself, there are a number of ways
that he can do so. I appreciate that it is almost impossible to remove
all possessions from prisoners that they could use to harm themselves.
Moreover, to do so would be to remove some of the sources of dignity
which prisoners rightly value highly. Removing an obvious weapon
such as a razor seems reasonable, but to remove all potential means
of a prisoner harming himself would only be justified in cases where
there was a high risk of self-harm. As stated above, it is my view that
he should have been subject to ACCT procedures in light of the
psychiatrist’s assessment on 23 March. However as that was not the
case at the time of his death, there was no reason for the prison to
remove personal items, which might include glass, from his
possession. It is not possible to know whether the outcome might have
been different had an ACCT been in place. However it is more likely
that his possession of items such as glass might have been more
33
closely examined by prison and healthcare staff if an ACCT had been
in place.
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Family liaison
143. Being informed that a relative has died in prison may well be difficult,
and families react in different ways. Informing a family is an important
task, which requires great sensitivity. Families may have many
questions. It is not always possible for liaison officers to inform them of
a death in a timely manner, whilst having the full details available.
144. Nevertheless, it is important that families feel that they have been given
accurate information. The man’s family did not feel this was the case
for them. Over the subsequent days, the family liaison officer was
changed. The family sometimes had problems contacting people in the
prison, which led to a misunderstanding about the return of his
property. They said that liaison improved after an unsteady beginning,
but the fact remains that at a difficult time, the family did not always feel
fully supported.
The Governor should remind all staff dealing with bereaved families of
the importance of ensuring that any information given is accurate.
The Governor should ensure that, if the nominated family liaison officer
is unavailable, an alternative should be provided.
Clinical care
145. The family asked whether he should have been psychiatrically
assessed whilst he was in hospital after harming himself at
Kirklevington Grange, and whether he was discharged too soon. The
investigator discussed this with the clinical reviewer.
146. The hospital should arrange for psychiatric assessment if they judge
that it is urgently required. The clinical reviewer said that this would
have been a decision made by the hospital, which is beyond the remit
of this report. He said that there was no reason to think that the man
did not receive full and appropriate treatment from hospital. Nor is
there any reason to believe that he was discharged before hospital
staff were content that he was fit to be so, irrespective of any views
prison staff may have had.
147. The clinical reviewer notes that on admission to Holme House, the man
was seen by the duty doctor and a registered mental health nurse.
They both judged that he did not present a risk of harming himself
again at that point. He was admitted to the healthcare centre as an in-
patient, and seen for a full mental health assessment the following day.
He had regular contact with the mental health team.
148. The family asked whether taking medication in Holme House is
monitored. Medication which is not held in a prisoner’s own
possession is distributed by trained healthcare staff who make every
effort to ensure that the medicine is taken correctly. It is not possible to
35
be absolutely certain that a prisoner who is determined not to take his
medication has in fact done so.
149. The clinical reviewer notes that the man was not reviewed by a doctor
between 9 and 23 March, although his medication was reduced twice
in that time. When admitted to healthcare following a mental health
review on 23 March, he was placed in a camera cell with no indication
of who was responsible for observing him or how this should be
recorded. His medical record contains no entries of what, if any,
contact took place between him and clinical staff after his admission to
healthcare.
150. In conclusion, the clinical reviewer considers that until his move into the
healthcare centre, he received a level of care that was as good as he
would have received in the community. He had frequent contact with
healthcare staff and received all the prescribed medication. When
found to have harmed himself on 27 March, he received prompt and
well co-ordinated medical attention, and he notes that the staff involved
should be commended.
151. He does note that there is a lack of clarity as to who has overall clinical
responsibility for patients in the healthcare centre in Holme House. He
says that the lack of contemporaneous entries in the man’s medical
record make it impossible to comment on the care he received in the
healthcare centre after 23 March. He was admitted to the centre as the
psychiatrist felt that he was acutely mentally unwell, psychotic, and at
risk of harming himself or others. Whilst there is no evidence of any
major problems between 23 and 27 March, there is similarly no
evidence of adequate clinical care. This does not mean that the care
was not there, but it does mean that the level of care cannot be
assessed.
152. The clinical reviewer recommends that the role of people making
entries into medical records should be identified, as should be
instructions on the frequency and recording of observations and
consideration of opening ACCT documents. He also recommends that
regular, relevant clinical entries should be made in all in-patients’
medical records, that a policy should be considered for clinical
responsibility of in-patients, and arrangements for regular reviews.
153. I endorse the clinical reviewer’s recommendations, and draw the Head
of Healthcare’s attention to them. In an Ombudsman’s report on a
subsequent death in Holme House from April 2010, I recommended
that the Head of Offender Health should review record keeping. This
recommendation was accepted, and so I do not repeat the
recommendation in full. However, I ask the Head of Healthcare to
report on this review in the action plan submitted to this office in six
months time.
36
The Head of Healthcare’s contribution to the six-month action
plan should include comments on the review of record-keeping.
Support for prisoners
154. The prisoner said that he received no counselling after the man’s
death. Immediately after the prison heard that he had died, the
prisoners in the cells on either side were spoken to and offered
support. The following day all prisoners on the healthcare centre who
were the subject of ACCT documents had reviews. Samaritans and
Listeners (prisoners trained by the Samaritans) are available to
prisoners in the healthcare centre. It seems to me that support was
available if required, and so I do not make a recommendation. The
Governor will wish to satisfy himself that sufficient support is made
available to prisoners in the healthcare centre after a death in custody.
37
CONCLUSION
155. The man was a 41 year old man serving four and a half years
imprisonment. After initially settling into his sentence and transferring
to a low-security prison, he began to develop mental health issues,
probably due to smoking cannabis. He developed a sense of paranoia,
which culminated in a serious self-harm attempt in Kirklevington
Grange in the early hours of 18 February 2009. Staff called an
ambulance and performed first aid until it arrived, and he was taken to
hospital.
156. In hospital, he continued to display signs of paranoia. He was placed
on an ACCT, and was released to Holme House, a prison with 24 hour
healthcare. Assessed on arrival, he was allocated to the healthcare
centre for observation. He seemed to improve, was moved to normal
location, and the ACCT was closed. However, when assessed by his
psychiatrist on 23 March 2010, signs of psychosis caused some
concern. He was moved back to the healthcare centre for observation
but, despite the psychiatrist having concerns that he might be a risk of
harming himself, an ACCT was not opened.
157. The man remained on healthcare in a camera cell, but staff were not
clear about the level of observations. After moving from the
houseblock, there were delays in him receiving his canteen provisions.
Clinical records do not show what level of treatment he received.
158. On 27 March, staff, including his mental health key worker, did not note
any apparent immediate problems. He interacted with staff and
prisoners throughout the day. One prisoner said that he thought he
had seemed “down”, but that seemed to be the only indication of any
particular problems. His mental health key worker arranged to see him
after another week, also suggesting no immediate concerns.
159. After the prisoners were locked into their cells for the night, the man
used a piece of glass from a broken coffee jar to cut his neck. Staff
noticed on the CCTV monitor that there seemed to be a problem and,
when they went to check, they found that he had injured himself
seriously. They made extensive efforts to treat him, even while he tried
to repel their help. An ambulance arrived and took him to hospital, but
emergency staff were unable to save him.
160. Overall, I feel that he received reasonable care whilst in custody.
There were, however, areas in which he was let down. It is impossible
to say whether these failings had a direct impact on his decision to take
his own life, but I make ten recommendations. The clinical reviewer
makes three recommendations, covering clarity of the roles of people
making entries in medical records, consideration of the level of
observation and support for prisoners thought to be at risk of self-harm,
and clarity over the responsibility for clinical care. I endorse these
recommendations.
38
RECOMMENDATIONS
1. The Head of Healthcare should consider ways of ensuring that when
prisoners display signs of psychiatric problems, their community doctor
is contacted to obtain any relevant medical history.
The National Offender Management Service partially accepted this
recommendation. They gave the following comments:
“If prisoners display symptoms of mental health concerns, a referral is
completed for the mental health team to triage an individual’s needs.
The mental health team within HMP Holme House complete a CPA (Care
Programme Approach) check for all patients referred to the team.
The team has access to remote access laptops which enables information
to be obtained immediately from the TEWV (Tees Esk Wear Valley)
PARIS records system. (A prisoner’s community doctor would only be
contacted directly if such information could not be accessed and this is
why this particular recommendation has been partially accepted).
Links with community teams are maintained and communication has
greatly improved.”
2. The Governor should consider how to involve a prisoner’s family in the
ACCT procedures in accordance with ACCT guidance.
This recommendation was accepted. The following comments were
offered:
“This is included in the current local Safer Custody Protocol/Policy. ACCT
Case Managers to be reminded via Notice to Staff. Draw specific attention
to this aspect during ACCT Case Manager training. Those managers
requiring ACCT Case Manager training to receive such training.
Under the Care Programme Approach (CPA) process family input is also
encouraged. The mental health team are currently working towards CPA
meetings for all secondary care patients. If a patient is open to mental
health services and currently within the ACCT process. Partnership
working is essential.”
The action plan was updated after six months with the following
comments:
“If it is identified that a prisoner’s family or family member should be
included in his ACCT procedures and the prisoner gives his consent, the
family will be included. This is emphasised during ACCT Case Manager
training.
39
To (November 2010) only 3 operational managers require ACCT Case
Manager training. All nurses in bands 5 and above have received ACCT
Case Manager training.”
3. The Governor should ensure that all visiting staff dealing with prisoners
are aware of the ACCT process and how to initiate an ACCT.
The National Offender Management Service has accepted this
recommendation and gave the following comments:
“As part of their induction, all staff receives guidelines on how to engage in
the ACCT process.
Healthcare Manager to review staff competencies re ACCT procedures
and report findings and recommendations to Head of Residence.”
The six month progress report gives the following update:
”All staff new to Holme House makes contact with a number of
people/departments including Safer Custody and receive guidance on the
ACCT process and who to contact for advice.
Most nurses have completed the ACCT Foundation training. The nurse
who is responsible for training is aware of this and submits a request for
nurses to be placed on training when advertised by the Training
Department.
ACCT Foundation training is delivered once a month on the training
closedown day. Additional training to target certain areas i.e., Education,
can be accommodated.”
4. The Head of Healthcare should ensure that warning signs on medical
records of the potential for self-harm lead to consideration as to
whether an ACCT should be opened.
This recommendation was accepted. The following comments were given:
“Previous history of self-harm is identified on reception template on
System 1. This then triggers a patient status marker (icon) on the patient’s
electronic clinical record, visible to all clinical staff only.”
5. The Governor should ensure that post-closure ACCT reviews are held,
in accordance with the ACCT guidance.
This recommendation was accepted. The following comments were given:
“Post closure reviews are held 7 days and one month following the closure
of ACCT documents as per the local Suicide and Self-Harm Prevention
Policy.”
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The action plan gives the following update after six months:
“The Safer Custody Team retains the ACCT Post Closure Review log and
informs the relevant Houseblock Manager/ACCT Case Manager of all
reviews and when they are required by.
Houseblock Manager/ACCT Case Manager returns completed ACCT Post
Closure review to the Safer Custody Team which is filed.”
6. The Head of Healthcare should review the camera cell policy at regular
intervals to ensure that it is being adhered to.
The National Offender Management Service accepted this
recommendation. They offered the following comments:
“Immediately following the death of the man a local action plan was written
up and acted upon.
The Head of Safety & Decency and Head of Offender Health reviewed the
Camera Cell Policy. It has been in use as of 01.02.10.”
The six month progress report contains the following comments:
“The Duty Governor, in liaison with the Nurse in charge of the In-Patient
Unit, will make the decision to place a patient in a camera cell. There is
now clarification of the role of the member of staff – discipline or clinical –
detailed the role of monitoring a camera cell and when and how to
document observations and interactions.
The local policy states a minimum of four face to face interactions as well
as observations will take place.”
7. The Governor should consider whether systems to ensure that property
travels with prisoners when they move location are adequate.
This recommendation was accepted. The following comments were
offered:
“Already system in place for property to transfer with prisoners when they
move locations from one part of the establishment to another. System is:
The prisoner takes his property with him on a planned move.
Staff carry out a cell clearance and take the property to where a prisoner
has been re-located when a move has not been pre-planned.”
The six month action plan contains the following comments:
“This system is still in place and works well.”
41
8. The Governor should remind all staff dealing with bereaved families of
the importance of ensuring that any information given is accurate.
This recommendation was accepted with the following comments:
“Unfortunately, in this instance, from a team of 4 Family Liaison Officers:
• One had transferred to another establishment;
• One had very recently taken temporary leave from being an active FLO
due to the recent unexpected death of her father.
• The initial FLO had also recently lost a close relative and was quickly
replaced by the incoming FLO who had been on annual leave when the
man had died.
Following the death of the man, a Notice to Staff was issued requesting
expressions of interest from staff to undertake the role of FLO. Training
was given to an additional member of staff and there are now 4 active
Family Liaison Offices at Holme House.
Another Notice to Staff inviting expressions of interest from staff to
undertake the role of Family Liaison Officer will be issued.”
The six month progress report comments:
“It is that a nominated Family Liaison Officer deals with family members to
ensure consistency. A comprehensive log is maintained and the FLO
updates the Head of Safety & Decency on a regular basis. Once the work
of the FLO is complete, the log is filed with all other documentation for that
prisoner ready for the PPO investigation and subsequent inquest.”
9. The Governor should ensure that, if the nominated family liaison officer
is unavailable, an alternative should be provided.
This recommendation was accepted. The comments and update offered
were as for recommendation eight.
10. The Head of Healthcare’s contribution to the six-month action plan
should include comments on the review of record-keeping.
This recommendation was accepted. The following comments were
offered:
“A sample of electronic clinical records are audited on a monthly basis. 30
random records are checked in house, in addition to a small sample
required by Community Services record keeping audit.”
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