Individual at Bristol

Investigation into the circumstances surrounding the
death of a man
at HMP & YOI Bristol in March 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2011
This is the report of an investigation into the circumstances surrounding the death of
a man, a prisoner at HMP Bristol. He died in March 2010. He was 41 years old. He
was found hanging in the cell which he shared with his son, his co-defendant, who
was at work at the time. I would like to offer my sympathy and condolences to his
son and the rest of his family for their loss.
The investigation was carried out on behalf of the Ombudsman by my colleague
assisted by his colleague. I would like to thank the Governor of Bristol and his staff
for their co-operation during the course of our enquiries.
The local Primary Care Trust (PCT) was commissioned to conduct a clinical review
into the standard of healthcare the man received whilst in custody at HMP Bristol.
The PCT appointed a clinical reviewer. I would like to thank him for the review.
Unfortunately, I did not receive the clinical review until December 2010, which
contributed to the delay of my own report (partly also due to the difficulty in speaking
to certain members of staff).
This was the man’s first time in prison and he spent much of the time feeling
anxious. He had a history of depression, but did not always take his medication. He
was monitored by suicide prevention measures on two occasions during his time in
custody. The first time staff had noticed that he was worried by prison life. The
measures were stopped once he had settled in but were put in place a second time
after his apparent attempt to take his life on 25 February. After a few weeks, his
mood appeared to lift and the measures were again removed. Unfortunately, just
over two weeks later, he took his life.
His demeanour was affected by his imprisonment. I have found that prison staff tried
to help him cope with his change in circumstances. I examine the use of suicide
prevention measures. Although I believe that staff acted in good faith, my report
identifies a number of areas where the suicide prevention processes could have
been improved. In particular I am disappointed to repeat a previous
recommendation about reviews after the suicide prevention measures come to an
end. I also look at the concerns raised by his family. My recommendations concern
suicide prevention procedures, and mental health assessments. I also highlight an
area of good practice.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman July 2011
2
CONTENTS
Summary
The investigation process
HMP Bristol
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
1. The man was remanded into HMP Dorchester on 8 December 2009 charged with
serious offences. It was his first time in custody and he struggled with his
change in circumstance. His son had been remanded with him as his co-
defendant, and this support did help him to a certain extent. However, suicide
prevention measures were used, but were closed once he began to adapt to life
in prison.
2. He and his son were transferred to HMP Bristol on 15 January. During his initial
healthscreen interview at Bristol, he explained that he was anxious, had a history
of depression and had taken an overdose ten years previously. His main
concern was being able to share a cell with his son, which was authorised on 23
January.
3. On 3 February, Dorchester healthcare department emailed Bristol regarding a
mental health referral that had been made for him, but had not taken place
before he transferred. He was assessed two weeks later, on 16 February, by a
mental health nurse who did not think that he showed clear signs of depression,
but was somewhat anxious. As a result of the mental health assessment, he
was referred to a counselling service.
4. He was a quiet prisoner who did not often come out of his cell. He and his son
did not associate with many of the other prisoners. They were employed in the
prison’s workshop. He hung himself in his cell on 25 February but his son raised
the alarm before he was injured. He was taken to the healthcare centre where
he was assessed by a member of staff. Suicide prevention procedures were
begun and he attended a number of reviews to monitor his well-being and state
of mind. At a review on 7 March, he said that he regretted the alarm caused by
his actions and would not attempt to harm himself again. The suicide prevention
measures were stopped.
5. At the end of March his son returned to their cell after his morning work shift to
find his father hanging. Officers and healthcare staff attempted to resuscitate
him but the prison doctor certified his death a short while later.
6. This report contains eight recommendations. I also highlight an act of good
practice regarding communication between Dorchester and Bristol.
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THE INVESTIGATION PROCESS
7. One of my investigators opened the investigation at HMP Bristol on 6 April 2010.
He met senior prison managers and took copies of the documentation relating to
the man. Notices of the investigation were issued to staff and prisoners, inviting
those who wished to provide information regarding his death to make themselves
known to the investigator. No-one came forward with regard to the notices. My
investigator and his colleague visited the prison on 5 and 10 May, and 5 August,
to interview staff and prisoners. Another investigator visited HMP Portland to
interview an officer on the investigator’s behalf on 24 May 2010. The officer had
been on detached duty at Bristol at the time of the man’s death, and has since
returned to Portland. The investigator subsequently returned to Bristol on 2
December to interview a further member of staff.
8. My investigator wrote to the Chief Executive of the local Primary Care Trust
(PCT) to commission a clinical review. Bristol PCT asked a clinical reviewer to
review the care received by the man whilst at HMP Bristol. He received a copy
of the relevant medical documents upon which he based his findings.
9. One of the Ombudsman’s Family Liaison Officers (FLOs) contacted the man’s
family at the beginning of the investigation. He explained the investigation
process and offered the opportunity to raise any questions or concerns they
would like addressed. My Senior Family Liaison Officer then took over as the
family liaison officer. She visited the family with my investigator on 17 May. At
this meeting, the family raised the following issues:
• They were concerned about the man’s son, who was sharing a cell with
his father. They wanted to ensure that he was being looked after
properly.
• They were worried that the man had not taken his anti-depressant
medication whilst he was in prison.
• They asked about the process of checking prisoners’ outgoing mail.
The family felt that if his mail had been monitored, prison staff may
have noticed his intentions and watched him more closely.
• The man’s father wrote to the Governor of Bristol to express his
concern for his son and grandson after his son’s first suicide attempt.
He was unsatisfied with the letter he received back.
• The family were surprised that the man’s son was double-handcuffed
to a prison officer at his father’s funeral and asked whether this is
compulsory.
• They wished to have all of his property returned to them.
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HMP BRISTOL
10. HMP Bristol is a Category B prison for the West of England. Prison Service
Order (PSO) 0900 (Categorisation and Allocation) explains the reason for
categorising prisoners:
“Prisoners must be categorised objectively according to the likelihood
that they will seek to escape and the risk that they would pose should
they do so.”
11. Category B prisoners are defined in the PSO as:
“Prisoners for whom the very highest conditions of security are not
necessary, but for whom escape must be made very difficult.”
The PSO also explains the situation for un-sentenced prisoners:
“All prisoners on remand awaiting trial, or convicted and awaiting
sentence, other than those provisionally categorised A, are to be
placed in Category U (Unclassified). Category U prisoners will
normally require Category B accommodation … “
12. The prison receives male prisoners and a limited number of young offenders,
both convicted and remand, from all the local courts. This results in a high
turnover of prisoners. The prison can accommodate up to 606 adult male
prisoners across seven wings. The first night centre is located on A wing along
with the induction wing and detoxification unit. It also has a separate
healthcare unit.
13. The local Primary Care Trust (PCT) provides the prison’s healthcare services.
The healthcare centre has 20 in-patient beds. Mental health services are
provided by Avon and Wiltshire Partnership Trust and six registered mental
health nurses provide support to prisoners on a full-time basis.
Assessment, Care in Custody and Treatment
14. Assessment, Care in Custody and Treatment (ACCT) is a care planning tool
used by prisons to help support and monitor those prisoners identified as being
at risk of suicide or self harm. The ACCT is a multidisciplinary process that
encourages staff to work together to provide individual care to prisoners in
distress and help to diffuse circumstances where self harm or suicide may
occur. Prisoners are checked at specified but irregular intervals.
Multidisciplinary case reviews are central to the ACCT process. The prisoner is
invited, along with staff involved in his care, to discuss his level of risk and
identify any additional actions that might help reduce that risk. A post closure
review should be held after the procedures have been closed.
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Personal officer scheme
15. Each prisoner at Bristol is assigned a personal officer who acts as a point of
contact should they need help. This officer is required to have regular
conversations with the prisoner and record these interactions. In the latest
inspection report of Bristol of January 2009, HM Chief Inspector of Prisons said
that: “personal officer entries in history files were made regularly and all but one
of the files we reviewed were up to date”.
Her Majesty’s Chief Inspector of Prisons
16. With regard to self-harm and suicide, the Chief Inspector recommended in her
previous inspection of HMP Bristol in January 2005 that there should be a safer
custody strategy to help reduce the risk of self-harm. She also asked that the
role and responsibilities of Listeners should be clarified. (Listeners are trained
by the Samaritans to provide emotional support to fellow prisoners in distress.)
During the more recent inspection in January 2009, the Chief Inspector found
that:
“Self-harm and suicide were covered by an up-to-date policy and
managed by two visible and proactive safer custody managers.
Assessment, care in custody and teamwork (ACCT) documentation
was mostly good and prisoners at risk were managed with care.
Incidents of self-harm had decreased. There was a well-supported
group of Listeners but access for young adults was unnecessarily
restricted. There was good contact with prisoners’ families.”
Independent Monitoring Board
17. Each prison has an Independent Monitoring Board (IMB) made up of members
of the community. The Board’s role is to ensure that the prison is properly run
and that prisoners are treated decently. Each Board produces an annual report
for the Secretary of State. In its most recent report from August 2009 to July
2010, Bristol IMB noted that the number of Listeners has increased to nine, and
there are plan to increase them further to 12. The report also noted an
increase in ACCT monitoring procedures being used, but said that this was due
to a better system of recognising need.
Previous deaths at Bristol
18. Since the Ombudsman was given responsibility for investigating all deaths in
prison custody for England and Wales in April 2004, there have been seven self
inflicted deaths at HMP Bristol. The last death was only a few days earlier than
the man’s on 26 March 2010. In one of the cases, a recommendation was
made regarding ACCT post-closure interviews. Disappointingly, I have
repeated this recommendation here. Although it is impossible to know what
difference it might have made in the case of the man, I believe the Governor
should seek to address it as soon as possible.
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KEY FINDINGS
19. The man was remanded into the custody of HMP Dorchester on 8 December
2009 charged with a number of serious offences. His son was remanded with
him as his co-defendant. He had previously come into contact with the legal
system but this was his first time in prison. A suicide/self-harm warning form
was opened by escort staff as he had seemed very depressed while at court.
Once at Dorchester, he told staff that he was very anxious because he had
been told he could not share a cell with his son as they were potentially
category A prisoners. (Category A prisoners are those whose escape would be
highly dangerous to the public or national security.) He was identified as at risk
of harming himself and the Assessment, Care in Custody and Treatment
(ACCT) monitoring procedures were put in place.
20. At the beginning of the ACCT monitoring procedures, he was observed hourly.
There were no Listeners in the prison at the time, but he was told that he could
access the Samaritans’ telephone line at any time by asking staff. He was too
upset to answer whether he had any suicidal thoughts or intentions but said
that he “felt the lowest that he could”. He told staff that he had taken an
overdose ten years ago that had required medical attention. At the case review
following the assessment interview, he was judged to be at a raised risk of
harming himself.
21. At the ACCT case review three days later on 11 December, he said that he was
still a little anxious and would like the ACCT to stay open, but was happy to
reduce the amount of observations. The help and support offered to him was
fully explained and he was rated as being at low risk of harming himself. (His
risk had been assessed as still raised on 9 December.) While the ACCT
document remained open, he did not go out of his cell very much for exercise
or association. It appears from his prison records that he and his son were
quiet prisoners who kept their own company.
22. During the evening of 16 December, he said that some prisoners on the wing
landing were making inappropriate comments about himself and his son. He
did not mention any names and he was encouraged by Officer A to talk about
the incident to staff in the morning. His concerns were noted in the wing book,
and mention was made of opening an anti-bullying file. (This would instigate
formal procedures to try to stop the bullying.) My investigator saw no evidence
that an anti-bullying file was actually opened.
23. He had another ACCT review on 18 December. He said that he felt more
settled and agreed that there was nothing to be gained by having the ACCT
procedures in place any longer. He was reassured about the support available
to him. He told staff that he was aware that if he began to feel low again, the
ACCT could be re-opened. The ACCT was then closed.
24. It was recorded in his medical file on 31 December that he had not been taking
Citalopram (an antidepressant drug he was prescribed) as he was too scared to
come out of his cell to collect it. It was also recorded that he had a score of
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moderate depression from the depression screening questions. There is no
record that this information was discussed with officers on the wing.
25. He and his son were transferred to HMP Bristol on 15 January 2010. During
his first reception interview, he stated that he was depressed and wanted to be
in the same cell as his son. Nurse A wrote that he said that he did not feel like
harming himself or committing suicide. Although she could not specifically
remember her conversation with him, during an interview for this investigation,
she agreed that she described his emotional state as good and his behaviour
and mental state as “stable”. It does not appear that he told her that he had
previously been prescribed antidepressants. She would not, at that time, have
seen his medical record at Dorchester which would have shown that he had
been prescribed Citalopram.
26. It is the responsibility of the sending prison, (that is Dorchester), to ensure that
all of the prison records go with the prisoner on transfer. Unfortunately, it
appears that his prescription charts did not go with him, although his medical
record did.
27. He was authorised to share a cell with his son on 23 January. During an
interview with the investigator, Officer B (his personal officer), said that both
father and son were appreciative of this and seemed happier. A prisoner in the
servery came forward to tell staff that he and his son were not regularly
collecting their food at mealtimes. When the officer spoke to them, they said
that they did not have any problems and did not have large appetites.
28. The officer made a note in the man’s records on 2 February. The officer
explained to the investigator that the son had knocked into another prisoner
who had “got verbally aggressive”. The man told the officer that he was
concerned for his son. The officer spoke to the other prisoner who confirmed
that he “thought nothing else of it”, which he reported back to him.
29. His wing sheet revealed that, although staff considered it to be helpful to him to
be able to share a cell with his son, he was very quiet and did not come out of
his cell very much. The investigator has heard conflicting explanations for his
reluctance to leave his cell. Prison staff made reference to him being afraid to
leave his cell. However, his son told my investigator that they simply preferred
keeping themselves to themselves. Officer C told the investigator that, during
February, he tried to get him a job as a wing cleaner. During interview, the
officer said “… my impression was that they were both quiet and timid prisoners
really, quite reclusive”.
30. On 3 February, Bristol received an email from Dorchester about a mental health
referral that had been arranged for him, but had not taken place before his
transfer. The referral had been made because he had not taken Citalopram for
approximately four weeks.
31. The assessment was undertaken nearly two weeks later on 16 February by a
Registered Mental Health Nurse. He noted that he had not suffered any side
effects from the medication and did not display signs of being depressed.
9
However, he said that he was of “low mood”. They discussed the fact that he
had been too scared to leave his cell at Dorchester to collect his medication.
He said that he had been quite intimidated in the medication queue. Nurse B
explained that staff had various options when prisoners appear frightened to
leave their cells and they can deliver the medication to the prisoner.
32. During the mental health assessment, the nurse wrote on the form that he had
been sexually abused and so he would refer him to a counselling service. “Re-
start Citalopram 10 mgs” is written on the form. During interview, the nurse
said that this was a note to himself to speak to the doctor about it. He said that
he specifically asked him about any thoughts of suicide and he denied them.
The nurse found no evidence of serious mental illness.
33. The nurse told my investigator that he spoke to the doctor after this assessment
and explained that he had discharged him from the mental health team
caseload. When asked if he spoke to the doctor about the possibility of
resuming the prescription for Citalopram, the nurse said: “I presume I would
have. I can’t honestly say because I can’t remember that far back to be honest
with you”. No conversation with the doctor is recorded on the electronic record
but the nurse said that this was because he was still familiarising himself with
the electronic system. The nurse said that he would have spoken to the doctor
and agreed that there was no need for him to be re-prescribed Citalopram. He
was not able to recall the name of the doctor.
25 February – the man’s first attempt to harm himself
34. At 9.04pm on 25 February, the man attempted to hang himself in his cell. He
used a ligature made from his shoelaces tied to the bed frame. His son was
asleep but woke to find him and raised the alarm. He had left a note on the
back of a photograph saying “Love you all, no one believed me, sorry.” Staff
intervened and he had not lost consciousness at the time that the alarm was
raised.
35. He was taken to the healthcare centre and, following authorisation from the
duty governor, placed on constant supervision under ACCT monitoring
procedures until the first assessment interview was conducted. (Constant
supervision is when a member of staff sits outside the cell and watches the
prisoner at all times to prevent any attempt to harm himself. The member of
staff should also interact with the prisoner to provide further support.) A
Listener went to the cell and spent some time talking to him. The ACCT
immediate action plan also required the Samaritans’ telephone system to be
explained, and for healthcare staff to have regular conversations with him.
36. The ACCT assessment interview was undertaken at 9.00am the following
morning by a Senior Officer (SO) A (the Safer Custody Manager).
(Unfortunately there are a number of incorrect references in the ACCT
document which name the man incorrectly. The SO told the investigator that
this was a clerical error.)
10
37. The senior officer recorded in the ACCT assessment that the man said that he
had recently had “issues with a co-defendant which has added to pressures
already gained since being in prison”. (This reference is to another co-
defendant and not to his son.) With regard to his attempt to hang himself, he
said that he had “a second of madness” and, as the ligature became tighter
around his neck, he panicked and released the pressure. He told the SO that
he did not have any previous history of self-harm or suicide attempts. He
stated that he was fine and that he felt “guilty and selfish”. He said that he had
scared himself and had no further thoughts of self harm. It was discussed
during the interview that he had three children, a wife and a business which
were all reasons for him to carry on living. The SO recommended that he
should be relocated from the constant supervision cell to the healthcare centre.
38. The SO stated in interview that during the ACCT assessment the man:
“ … talked about what he’d done the night before, very openly. He felt
very guilty about doing it, he felt quite ashamed because he was in with
his son and I just led on with questions like you do through an
assessment. But he seemed quite relieved in a way that you know he
hadn’t gone through with it, you know that it was stopped and that he
didn’t actually kill himself.”
39. The ACCT caremap was completed by the SO and outlined the man’s concerns
and how staff could try to reduce his risk of harming himself again. Contacting
his family was a key priority and this was arranged to be done from the
healthcare office. On a separate form kept in the ACCT, information about the
telephone call to his wife was recorded by the SO. He had told the SO that he
did not want his wife to be told about his suicide attempt and so he said to his
wife that he was fine. The SO noted that the conversation was positive and his
mood improved substantially following the telephone conversation.
40. He also wished to leave healthcare and return to the wing to be with his son.
The SO wrote that he was to be monitored for another 24 hours before
arranging the move. His son needed to be told about his father’s well-being
and the SO agreed to contact the wing. He also told staff that he was bored so
wing staff were asked to find employment for him as part of his care plan.
41. At 10.00am the same day, the first ACCT case review was held in healthcare.
The review was attended by the man, a nurse, SO A and a governor. The note
of the meeting recorded that he said that he felt more positive in the morning
and had no thoughts of suicide or self-harm. It was noted that a telephone
conversation with his wife had been arranged and his son had been informed
that his father was coping. It also said that he was content to move out of the
constant supervision cell to a normal cell in the healthcare centre, and was
aware of the support available to him. His level of risk was identified as low.
There was no mention of his history of depression or outstanding mental health
assessment. It was agreed that hourly observations should be made during the
night and a conversation should take place each morning, afternoon and
evening.
11
42. In the ACCT document there is a form entitled “Review prior to discharge from
healthcare” but this was not completed. He returned to the wing at
approximately 10.30am on Saturday 27 February.
43. An officer recorded in his ACCT on-going record that he had spent time out of
his cell talking to other prisoners, and was glad to be back with his son. No
issues or concerns were raised by him on his return to the wing. It was
recorded in the ACCT document that he and his son had a visit on Sunday 28
February which raised their spirits.
44. His ACCT was reviewed on 1 March by SO A and an officer in the G wing
office. During the review he said that, although he felt much better and
regretted his attempt to harm himself, he was still in a “low mood”. The goals in
his caremap were mostly completed but he still had a problem with boredom
and it was suggested that he submit an application for employment. His risk of
harming himself was again assessed as low.
45. He was noted as attending education on 3 March and was described as “quite
cheerful” by Officer B. Later in the day, he was described as “being in good
spirits” by another officer.
46. A further ACCT review was held on 4 March on G wing with a SO and an
officer. He said that he still did not know why he had tried to hang himself and
could only put it down to the fact that he had “had a visit from his wife that day
and was thinking about missing her”. He said that he was not suicidal. He
repeated that he wanted to work and the staff attempted to facilitate this. The
SO and officer wrote that the ACCT was to remain open for another week to
ensure that he was given a further chance to settle. His level of risk and the
frequency of observations remained the same. The next review was scheduled
to be held on 11 March.
47. His personal officer, Officer B, wrote in the wing sheet on 7 March that he
seemed to have recovered from his low mood and deeply regretted harming
himself, especially because of the effect that it had on his son. On the same
day, he had another ACCT review with Officer B and a SO. The review noted
that he called his wife each day when his cell was unlocked. He was expecting
to be employed, along with his son, in the prison workshop which he was
looking forward to. Again, his mental health was not discussed and there was
no contribution from healthcare staff.
48. He told the officers that he would not attempt to harm himself again. SO A,
Officer B and himself agreed to close his ACCT document. According to the
record of this case review, a post-closure interview was scheduled to have
been held at 4.30pm the same day. It is not clear if this was a clerical error as
ACCT post-closure interviews at Bristol are usually scheduled between seven
and 28 days after closure. The investigator was told that a post-closure ACCT
interview did not take place.
49. He and his son continued to share a cell. They began work in the prison
workshop. During an interview with the investigator, Officer B stated that:
12
“… he [the man] did seem to brighten up a lot when he’d gone to work
and he was out more and more and he got more used to the other faces
around the wing.”
50. He was sent an appointment slip on 11 March for the Kinergy counselling
service. He returned the slip the same day saying that he did not want to
remain on the waiting list for the counsellor. His decision was not recorded on
the electronic medical record, and Nurse B was not informed that he had
changed his mind. Over the next two weeks, he continued to work in the prison
workshop with his son. The work shifts were from 8.30am to 11.45am and
1.30pm to 4.00pm. He did not have any further recorded contact with the
healthcare department, and there are no more entries in his history sheets.
31 March
51. On the morning of 31 March, his son went to work as usual. He stayed in their
cell as he complained of feeling ill. His son returned at 11.50am and Officer D
unlocked the door so that he could go back into their shared cell after the
morning’s work. The officer locked the door and then his son immediately
called from the cell that his father had hung himself.
52. The officer unlocked the door again and went into the cell. She found the man
hanging from the bunk bed. She told his son to leave the cell and called for her
colleague on the wing, Officer E. A general alarm was raised with an urgent
message for any healthcare staff to attend. Officer D could not remove her
anti-ligature knife out of her sealed pouch, and so the other officer removed it
for her. She lifted him under the arms and the other officer cut the ligature.
She moved the cabinet in the cell and they laid him on his back on the floor.
53. He was cyanosed (meaning that the skin looks blue due to a lack of oxygen)
and Officer D was unable to feel a pulse. Officer F arrived at the cell and
commenced chest compressions, whilst Officer E administered air using a
pocket face mask (a mask that allows rescue breaths to be given through a
valve). Officer D then left the cell.
54. In the meantime, Nurse C who was in the wing treatment room had been
informed by an officer of a ‘code blue’ (a code blue alarm signifies a medical
emergency related to breathing). He ran to the cell carrying the emergency
bag, then ran back and collected the oxygen emergency bag to take to the cell.
55. Nurse D arrived at the cell and took over administering air from Officer E, using
an ambu-bag (an ambu-bag is a hand-held device used to provide ventilation to
person who is not breathing). Two more nurses arrived and at 11.52am Nurse
E shouted for an ambulance to be called, which an officer said that they would
do. At 11.56am, Nurse E heard on the radio that a doctor had been asked to
attend. He shouted for the defibrillator as there was not one in the emergency
bag on the wing.
13
56. Two officers were running onto the wing when they heard the call for the
defibrillator and went to collect it from the healthcare centre. (A defibrillator is a
device that can restart the heart by giving it an electric shock. It cannot always
be used and can only provide a shock if there is sufficient electrical activity in
the heart.) Nurse F took over from Nurse D and administered air whilst Officer
F continued to administer chest compressions.
57. The doctor arrived and took over the ambu-bag from Nurse F. He inserted an
airway (a tube used to maintain a patient’s airway) and continued to administer
air. Nurse E cut the man’s shirt and an officer applied the defibrillator pads.
Nurse E then took over the chest compressions from Officer F. The defibrillator
advised the staff not to shock him and cardio pulmonary resuscitation (CPR)
was to be continued. At this point the officer took over the chest compressions.
(The defibrillator has an audio device which instructs staff on the procedures to
be followed.) The defibrillator again advised that no shock should be given and
to continue CPR. At 12.00pm, the doctor certified that he had died. The
paramedics arrived at 12.11pm.
Support for the man’s son and other prisoners
58. The man’s son was initially placed with other prisoners that he knew. Once his
father was pronounced dead, he was moved to the healthcare centre. He was
informed of his father’s death by the doctor and the ACCT monitoring
procedures were begun to provide him with further support. He continued to
work during the day and was also able to go back to the wing for association.
Support for staff
59. Officer E described the support offered by the prison to himself and his
colleagues as “brilliant”. He said that the care team offered support before a
debrief meeting with the Governor. Staff wrote out statements before being
taken home. The officer also stated that he knew that if he wanted to speak to
someone about the incident he could and was aware of the support available to
him.
60. However, Officer D was less happy with the support offered to her. During
interview she agreed the Care Team were very supportive, but she felt
pressured to return to work and did not feel that she was taken seriously.
Liaison with the man’s family
61. The man’s family arrived at the prison shortly after he died. They were taken
aside and told of his death. His property was returned to his family although
they were concerned that not all of his letters were included. A prison chaplain
took the funeral, and the prison contributed to the costs of it. His son attended
the funeral, although the family were unhappy that he was double-handcuffed
to an officer. The family told the investigator that they were grateful for the
support they had received from the prison following the death.
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ISSUES
Clinical care
62. The clinical reviewer makes a series of observations and recommendations in
the clinical review that I encourage the Head of Healthcare to review carefully.
In respect of the overall level of clinical care given to the man, he concludes: “I
do not feel there were significant differences in the care that was provided in
prison compared with the community”. However, he does acknowledge that a
prison environment provides further opportunities for supervision than that in
the community.
Mental health support
63. At Dorchester, the man refused to go to the treatment hatch to collect his anti-
depressant medication. Staff at Dorchester believed that this because he was
afraid to leave his cell. In the community, it is an individual’s choice to stop
taking anti-depressant medication. This is true of an individual in prison as
well, but the prison should ensure that it discharges its duty of care by following
up any prisoners who do not cooperate. The clinical reviewer notes in his
review that a physical assessment of the man would have been appropriate:
“In view of these symptoms I believe that a face to face review should
have been made prior to stopping the prescribing antidepressant
medication to assess if there was a mental health condition leading to
the non-compliance.”
64. Given the mood-altering nature of the medication, it is reasonable to expect the
healthcare services to follow up those who abruptly stop taking such
medication. He writes that it may have been appropriate to stop prescribing the
medication, but a face to face assessment would have enabled staff to check
on his mental state. I agree with him and make the following recommendation:
The Head of Healthcare at HMP Dorchester should ensure that where
compliance with mood-altering medication is poor and behaviour is
unusual a clinical face to face review should be carried out with the
patient.
65. It was reassuring to see that Dorchester contacted Bristol to inform them of the
mental health assessment that they had not had time to undertake. While it is
unfortunate that the man was transferred while awaiting an assessment, the
clinical reviewer notes that the communication between the prisons in this
specific instance was evidence of good practice. He says that:
“Dorchester healthcare subsequently contacted HMP Bristol to advise
that a mental health review had not been completed. This is evidence
of good communication between the clinical teams.”
15
The communication between Dorchester and Bristol healthcare
departments regarding the mental health referral is an example of good
practice.
Anti-depressant medication
66. Following the email from Dorchester, Nurse B undertook a mental health
assessment on 16 February. During the review, he wrote on the paper
document that he should speak to the doctor regarding the restarting of the
Citalopram prescription. However, when he put this information on the
electronic system, he neglected to include a record of the conversation he said
he had with the doctor. The clinical reviewer writes of this:
“The clinical opinion was that in this situation restarting Citalopram was
not appropriate … Documentation is not clear about who or when
assessments were completed and in this aspect record keeping should
be improved.”
The attempt to resuscitate the man
67. Following the discovery of the man, staff attempted to resuscitate him. The
clinical reviewer concludes:
“There is no evidence to suggest that the resuscitation was not handled
well. The man was declared dead in HMP Bristol by the doctor and so
resuscitation was stopped. This decision appears to have been
appropriately taken.”
68. Staff responded quickly when he was found hanging and the investigation has
not discovered anything of concern in the actions of the people involved in the
day. However, I agree with the finding of the clinical reviewer about the
following:
“The defibrillator was missing from the wing. Although this was
checked daily its absence had not been notified by the nurses to the
managers to organise its replacement. “
69. The lack of a defibrillator in the emergency bag on the wing was an oversight
that could have had serious consequences. It is well known that the quick
application of a defibrillator increases the chances of survival. It has not been
suggested to my investigator that the missing defibrillator made a difference to
the chances of survival for the man, but that would clearly not be so in every
case.
The Head of Healthcare should ensure that all defibrillators are in place
and working correctly.
16
Record keeping
70. The prescription charts did not travel from Dorchester with the man which
meant that the receiving prison, HMP Bristol, did not have all of the relevant
information at the time of his arrival. The clinical reviewer writes: “Drug charts
were not transferred from HMP Dorchester to HMP Bristol. This could have led
to delay in understanding the clinical picture”. The reviewer is also concerned
about the quality of some of the documentation in the healthcare records. He
comments that: “… in one area there was an almost incoherent mental health
note with no use of punctuation”. He makes a recommendation regarding
record keeping that I have rephrased in order to be consistent with previous
recommendations from my office:
The Head of Healthcare should ensure that the entries made in medical
documents are in accordance with the standards set out in the NMC
Guide to Record Keeping.
Assessment, Care in Custody and Treatment (ACCT) at HMP Bristol
71. The man was subject to ACCT procedures at Dorchester at the start of his time
in custody. Another ACCT was opened after his first attempt to hang himself at
Bristol. He was quickly identified as at risk of harming himself on both
occasions and I am satisfied that appropriate action was taken. The details of
his next of kin were clearly identified and included at the start of the ACCT
document which is a helpful way of ensuring that all relevant staff have access
to the information. However, there are several aspects to the ACCT
procedures at Bristol that raised concern.
The decision to place the man on constant supervision
72. Following his attempt to hang himself on 25 February, the man was
accommodated in the healthcare centre under constant supervision.
Constantly supervising a prisoner is the highest level of observation and should
only be used with prisoners who are deemed to be at very high risk of harming
themselves. I believe that this was an appropriate response by the prison given
the seriousness of his attempt to harm himself.
73. When a prisoner is deemed to require constant supervision, authorisation must
be sought. In this case the Duty Governor agreed to the decision over the
telephone. PSO 2700 (Suicide prevention and self-harm management)
requires the first case review to be held immediately prior to unlock the
following morning in cases where the prisoner is placed under constant
supervision during the night. The man’s review was held at 9.00am. This is
actually after prisoners were unlocked, but I am not minded to criticise the
prison as it is clear that he was reviewed early the next morning as required
and as practicable.
74. HMP Bristol’s Suicide / Self-harm Prevention Strategy document says:
17
“Being placed on constant supervision must trigger a referral for an
urgent mental health assessment”
75. The first case review held on 26 February does not mention a mental health
referral and there is nothing in the man’s medical record to show that this
assessment happened. When the investigator spoke to the Safer Custody
Manager he said with regard to mental health referrals for prisoners on
constant supervision:
“It’s not a standard practice but being on constant supervision the
healthcare have a massive input into that person and I can’t say for
sure if the mental health team get involved with every single case. …
Not an automatic referral no … “
76. The investigator was told by the Head of Healthcare that if a prisoner was
subject to constant supervision then they would, in effect, be assessed
continually. While this may be true, the policy clearly requires a formal
assessment to be undertaken to check on the mental health of the person
concerned. The ACCT process is there to support someone at risk of harming
themselves, while a mental health assessment provides an opportunity for staff
to assess the condition of a prisoner’s mental health at a particular point in
time.
77. Annexe 8Y to PSO 2700 makes it clear that:
“Where the prisoner is not already under the care of secondary care
mental health services, being placed on Constant Supervision must
trigger an urgent referral for mental health assessment and, if
appropriate, provision of care. PCTs/establishments should agree with
their mental health service provider protocols for urgent referrals based
upon clinical need.”
78. This lapse is particularly disappointing given that Nurse B had undertaken a
mental health assessment of the man on 16 February. The nurse was not told
that he had harmed himself and did not know that he had been placed on
constant supervision. The nurse had recent relevant knowledge of him and it
could only have assisted in his care and support if he had been involved.
During interview, the nurse reflected on the role which he might have fulfilled:
“I would have done another assessment and this would have given me
the evidence to say you’ve told me that you’re not feeling suicidal but
clearly you are, can we talk about this and can we discuss why, what
was going through, and then I would have identified trigger factors with
him. I would have identified why he felt like this and also is he going to
do it again, is he going to harm himself again, which is most important.”
79. He went on to explain how he may have got involved:
“But in this case what would happen would be the nurse; obviously I
can only say what in an ideal world, the mental health nurse down in
18
healthcare looks into the notes. They’ll see that he was seen by me, I
have previous knowledge, previous knowledge is always a good thing
to take into account, and I also have a relationship because I’ve seen
the person before. So they would then phone upstairs and say we
have somebody on constant watch, are you available to come down
and do an assessment on this person or is there anything you can give
me and use for them.”
The Governor and the Head of Healthcare should enforce their local
policy to ensure that a prisoner placed on constant supervision is
always referred for an urgent mental health assessment.
The decision to end the constant supervision of the man
80. PSO 2700 explains:
“Acute suicidal crisis may be temporary and one aim of the case
reviews should be to reduce the level of supervision progressively,
substituting alternative supports, as the prisoner’s condition improves.
This will involve some degree of risk-taking as it involves the prisoner
being allowed to gradually take more responsibility for him/herself.
Constant supervision must only be for the shortest time possible and
how the prisoner will be returned to normal location and/or a lesser
level of conversations and observations must be reflected in the
CAREMAP.”
81. The PSO also recommends (in Annexe 8Q) a progressive scale of reductions in
observation. SO A told the investigator that the prison would aim to reduce the
level of monitoring steadily:
“But we couldn’t move someone straight from a constant supervision
straight back to the wing. You know we’d never do that, we always do
it in steps constant supervision then goes to maybe a safer cell in the
healthcare. We then review it again so we review every day.”
82. The man was assessed as being at low risk of taking his life throughout the
time ACCT processes were used. However, he went from being observed
continuously to hourly observations at night, and one conversation each
morning, afternoon and evening. His observations were reduced abruptly but I
accept that he died some time (approximately three weeks) after the ACCT was
closed, and it might not have changed the outcome in this case.
83. However, this might not be so in every case so I make the following
recommendation:
The Governor should remind staff of the guidance in the PSO to
progressively reduce the level of a prisoner’s observation when they are
taken off constant supervision.
19
The lack of involvement of other staff in ACCT reviews
84. Although staff from other departments were involved in his ACCT case reviews,
I believe that the involvement of Nurse B, as the most recent mental health
nurse to have spoken at length to him, would have been most useful. The
nurse explained to my investigator how he would acted, had he been invited to
participate:
“What I tend to do if somebody’s on a constant watch is I like to do the
assessment separately from the ACCT assessor or from the case
manager just because it’s very overwhelming. And then I’ll try and sit
in on the case review just because I think it may be somebody friendly
for, and then you can prompt as well.”
85. During interview, the nurse said that recent staff changes have resulted in his
team being invited more frequently to participate in ACCT processes. I have
found that knowledgeable staff who know the prisoner are vitally important for
the ACCT process to work effectively and I would encourage the prison to
continue to develop this improved team-working.
20
The ‘Review Prior to Discharge from Healthcare’ form
86. PSO 2700 says:
“A pre-discharge Case Review must take place before a prisoner is
returned to ordinary location from being resident in the Healthcare
Centre. The Unit Manager (or Case Manager if different) from the
receiving residential unit must be invited to this review. If it is not
possible for them or a representative to attend, the reason why must be
noted in the ACCT Plan. What healthcare will be doing to continue
support of the prisoner must be clearly documented in the ACCT Plan.
The pre-discharge Case Review Team must:
(a) Undertake the actions as listed in the section (above) regarding
‘subsequent case reviews’, taking into consideration any additional risk
that may pertain to the move. (That is, this review should consider,
along with staff from the receiving location, how best to reduce risk
during and immediately following the move).
(b) Arrange a follow-up healthcare appointment.
The Case Manager must complete the ‘Review Prior to Discharge from
Healthcare’ form (page 18) and update the CAREMAP, frequency of
conversations and observations and trigger factors on the front cover
as required.”
87. The ‘Review Prior to Discharge from Healthcare’ form was not completed in the
man’s case. The Head of Healthcare told the investigator that it was her
understanding that it is the case manager’s responsibility to complete this form.
However, SO A said that this would be healthcare’s responsibility. There
appears to be some confusion amongst staff as to who should take
responsibility for the procedure. However, the PSO makes clear that it is the
responsibility of the case manager to complete the form. (If a prisoner is in
healthcare, the case manager should be a member of the healthcare team.) A
follow-up healthcare appointment should also have been made, but there was
no further involvement from the healthcare department in the ACCT process.
This review is a valuable tool for staff to discuss the care required when a
prisoner leaves healthcare and moves back to a location within the prison.
The Governor must ensure that that the ‘Review Prior to Discharge from
Healthcare’ procedures take place in accordance with requirements.
88. The man left the healthcare department in the morning of 27 February,
approximately 24 hours after his last case review. Therefore, a review was
undertaken, even if not in line with the requirements of the PSO.
The decision to close the ACCT
89. At the case review on 4 March, he told staff that he was not suicidal, but it was
agreed that the ACCT procedures should remain open for another week. The
21
next review was scheduled for 11 March. However, a further review was held
four days earlier than scheduled, on 7 March, when it was decided to end
ACCT procedures. PSO 2700 says:
“The ACCT Plan can only be closed once all the CAREMAP actions
have been completed and the Case Review Team judges that it is safe
to do so … The Case Manager must enter in the record of the final
Case Review why the Case Review Team feel it is safe to close the
ACCT Plan, and enter the date closed and date for a post closure
interview..”
90. It is important to note that the prison was not obliged to wait until 11 March to
have another ACCT review. Having an earlier review can be a good decision
so that staff can react to any changes in the mood of the prisoner. The staff
involved were also free to close the ACCT procedures if they were content that
it was safe to do so.
91. Given that it was nearly three weeks after the ACCT was closed before he took
his life, I do not suggest that a different decision would have changed the
outcome. However, the PSO states that, as with all case reviews, the
membership of the team should have been:
“One of the attendees must be the named Case Manager (and failing
that, the Manager responsible for the prisoner’s location), one a
residential officer who works in the area where the prisoner is located
and the other an appropriate member of non-discipline staff.”
92. No non-discipline staff, such as healthcare, went to his case review. Given his
mental health issues, and due to his stay in healthcare, it would have been
beneficial for a member of healthcare to have been involved in the decision to
close the ACCT. The clinical reviewer stated that:
“The man had a history of depression and a recent serious attempt to
hang himself. I would recommend that in this situation there should be
clinical input, ideally from a mental health trained nurse, when the ACCT
was reviewed.”
The Governor and Head of Healthcare should satisfy themselves that
healthcare staff are involved ACCT case reviews in accordance with the
requirements of the PSO.
The lack of a post-closure interview
93. PSO 2700 says:
“The Case Manager must enter in the record of the final Case Review
why the Case Review Team feel it is safe to close the ACCT Plan, and
enter the date closed and date for a post closure interview. The date of
the first post closure interview is a matter for the case review team to
decide but must be within 7 days of closure.”
22
94. My investigator was told that a post-closure interview did not take place. The
interview is a vital part of the ACCT process as it enables the prison to assess
whether the closure of the ACCT was appropriate, and ensure that the prisoner
is sufficiently supported. It is impossible to know whether one or two post-
closure interviews would have had any effect on the eventual outcome in the
case of the man. However, I am disappointed that this extra safeguard was not
in place for him. I repeat a recommendation that I made in a report following
the death of a prisoner at Bristol in October 2007, and encourage the Governor
to ensure that it is resolved quickly.
The Governor and the Safer Custody Manager should ensure that ACCT
case managers are aware of their responsibilities regarding post closure
interviews.
Contact with the man’s family
The letter received by the man’s father
95. The man’s father wrote to the prison to outline his concern about his son. The
prison replied by way of a short, unsigned letter that his father did not feel
adequately addressed the points which he had raised. My investigator has
seen no reference to the letter in the prison records, including his ACCT
document. Given that the letter expressed concerns about his state of mind, I
think that it is unfortunate that more attention was not given to his father’s
worries. I believe that it would have been useful for those with a responsibility
for caring for him to have been aware of his father’s concerns.
96. His father was also unhappy with the tone of the reply he received, and fact that
the letter was unsigned. Having seen the reply received by his father, I
encourage the Governor to remind staff of the need for correspondence to be
appropriate in tone and content.
Checking mail
97. The man wrote many letters to his family whilst he was in prison. These letters
expressed his deep unhappiness with being in prison and, over time, seem to
reflect a decline in his emotional stability. The family said that they expected
the prison to have checked the letters, and therefore to have been aware of his
declining stability. My investigator put this issue to the prison and they
confirmed that the prison only reads up to 5 per cent of the post which is sent
out by prisoners. It is therefore unlikely that the prison would have read all, or
any, of his letters or should have been expected to. I think it would be helpful if,
in the context of his worries, information of this sort had been explained to his
father.
23
Knife to fashion the ligature
98. The family was under the impression that he had used a knife to fashion the
ligature he used to hang himself. My investigator spoke to the prison who
confirmed that a knife was not used, and no knives were found in his cell.
The man’s property
99. The family were concerned that there were still some letters of his that had not
been returned to them. My investigator spoke to the prison who confirmed that
all the property had been returned.
The man’s funeral
100. The man’s son went to his father’s funeral. He was double-handcuffed
(meaning that his hands were hand-cuffed together and he was also cuffed to a
prison officer.) The family told the investigator that they considered this to have
been unpleasant given that he was at his own father’s funeral. The investigator
spoke to the prison who confirmed that all Category B prisoners are required to
be double-handcuffed when they are outside the prison.
101. Although the son had not been convicted or sentenced and so he should have
been classified as Category U, he was in a Category B establishment and was
therefore treated as a Category B prisoner. I understand how distressing this
was for his family. However, the son had been charged with a number of
serious offences and the prison has a responsibility to escort prisoners securely
outside of the establishment and prevent their escape. They were following
established protocols, and I do not make any criticism of the prison.
Support for staff
102. One member of staff, Officer D, was unhappy about some aspects of the care
provided to her by Bristol following the death of the man. She told another
investigator from my office that she felt pressurised to return to work before she
felt ready. She acknowledged that the care team were very supportive, but felt
uncomfortable in her dealings with the senior staff about her return. This
situation may have been exacerbated because she was away from her usual
workplace and colleagues.
103. She was obviously affected by the death of the man. This may have been
worsened by the fact that she usually worked at HMP Portland and had only
been in Bristol a few days where she may well not have known many of her
colleagues. Regardless of this, it is important for all prisons to be aware of the
duty of care they have to their staff in the aftermath of such a traumatic event.
104. However, it should be noted that the other staff involved in the incident spoke
favourably of the support offered to them by Bristol.
24
CONCLUSION
105. The man found it hard to adjust to prison life, and struggled during his time at
both Dorchester and Bristol. He was initially provided anti-depressants but then
stopped taking them. In the community, people have the right to choose to stop
taking their medication. However, in a prison setting with the duty of care that
implies, I believe that greater attention should be paid when prisoners stop
taking mood-altering medication. Dorchester alerted Bristol to the need for him
to undertake a mental health assessment which was a positive action.
106. I believe that staff attempted to reassure him and put the ACCT procedures in
place at appropriate times in order to further support him. However, my
investigation has drawn attention to a number of issues with the ACCT process
at Bristol. It was also disappointing to see that staff with recent knowledge of
him were not involved during the ACCT process.
107. His mental health seems to have declined while he was in custody and he was
assessed by a mental health nurse shortly before he first attempted to harm
himself. This nurse was not informed of his subsequent actions which meant
that he was unable to assist colleagues responsible for the ACCT. No mental
health assessment was undertaken when he was placed on constant
supervision which was another missed opportunity to ensure that knowledge of
his mental health was shared at a vulnerable time for him. Although he died
approximately three weeks after ACCT processes ended, it is important that
Bristol focus on the improvements they can make in this area in order to guard
against future deaths in custody.
25
RECOMMENDATIONS
1. The Head of Healthcare at HMP Dorchester should ensure that where
compliance with mood-altering medication is poor and behaviour is unusual a
clinical face to face review should be carried out with the patient.
The National Offender Management Service accepted this
recommendation, writing:
“Within the health care at HMP Bristol we will ensure that reports of non
compliance with medication are reported and a face to face review carried out.
Currently all clinicians and pharmacy pick up non compliance.”
2. The Head of Healthcare should ensure that all defibrillators are in place and
working correctly.
The National Offender Management Service accepted this
recommendation, writing:
“There are defibrillators on all wings these are checked daily and recorded as
such.”
3. The Head of Healthcare should ensure that the entries made in medical
documents are in accordance with the standards set out in the NMC Guide to
Record Keeping.
The National Offender Management Service accepted this
recommendation, writing:
“Documentation audits are carried out each year to ensure compliance with
this.”
4. The Governor and the Head of Healthcare should enforce their local policy to
ensure that a prisoner placed on constant supervision is always referred for an
urgent mental health assessment.
The National Offender Management Service accepted this
recommendation, writing:
“All Prisoners placed on constant supervision receive a referral to the MHT.
Case managers will be made aware that an urgent MH referral not a routine
referral is required for prisoners on constant supervision.”
5. The Governor should remind staff of the guidance in the PSO to progressively
reduce the level of a prisoner’s observation when they are taken off constant
supervision.
The National Offender Management Service accepted this
recommendation, writing:
26
“Suicide Prevention Strategy will be reviewed and to state that all prisoners
coming off constant supervision will be located in Healthcare for a minimum
period of 24 hours on hourly observations. LNTS reminding all staff of policy to
be released.”
6. The Governor must ensure that that the ‘Review Prior to Discharge from
Healthcare’ procedures take place in accordance with requirements.
The National Offender Management Service accepted this
recommendation, writing:
“LNTS to be released reminding all residential wing managers not to accept
prisoners from Healthcare until a Review prior to discharge from Healthcare is
completed.”
7. The Governor and Head of Healthcare should satisfy themselves that
healthcare staff are involved ACCT case reviews in accordance with the
requirements of the PSO.
The National Offender Management Service accepted this
recommendation, writing:
“Case managers to be briefed that any ACCT CAREMAP issues regarding
healthcare must involve a member of the nursing team attending the review.”
8. The Governor and the Safer Custody Manager should ensure that ACCT case
managers are aware of their responsibilities regarding post closure interviews.
The National Offender Management Service accepted this
recommendation, writing:
“LNTS to be released reminding ACCT Case managers of their responsibilities
regarding post closure reviews.”
Good practice
1. The communication between Dorchester and Bristol healthcare departments
regarding the mental health referral is an example of good practice.
27