Individual at Manchester

Investigation into the circumstances surrounding the
death of a man
at HMP Manchester in June 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2011
This is the report of an investigation into the circumstances of the death of a 29
year old man who was found hanging in his cell in HMP Manchester in June
2010.
I extend my sincere condolences to the man’s family and friends for their loss. I
apologise for the delay in issuing this report and for any additional distress this
may have caused.
The investigation was carried out by my colleague. A review of the man’s
clinical care was carried out by a clinical reviewer on behalf of the local Primary
Care Trust. I am grateful to him for this review. I should like to thank
Manchester’s Governor and his staff for their co-operation.
The man had been at HMP Forest Bank for almost a year by early May 2010
when he escaped from prison. He remained at liberty for only a few weeks
before being recaptured and taken into HMP Manchester. He was sentenced to
nine and a half years imprisonment and categorised as a Category A prisoner
as he was deemed to be at high risk of attempting to escape.
For much of his time in Manchester, the man received additional support and
monitoring by staff as he was recognised to be a risk to himself. He was
experiencing marital difficulties and described this as one of the factors causing
him distress. These support and monitoring measures were still in place when
he died, less than a month after his arrival into Manchester.
I make three recommendations. One is about improving support for Category A
prisoners. Another is about the need for staff to record significant
conversations with prisoners. The third is about night time checks on prisoners
on the Category A wing. I also commend two members of staff for the way they
dealt with the man’s family after his death. In addition to my recommendations,
the clinical reviewer makes 10 recommendations (as well as reiterating a
recommendation made in my report).
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 Ombudsman December 2011
2
CONTENTS
Summary 4
The investigation process 6
HMP Manchester 7
Key findings 9
Issues 24
Conclusion 32
Recommendations 33
Commendations 33
3
SUMMARY
The man was a 29 years old and was found hanging in his single cell in HMP
Manchester in June 2010. He had first arrived in custody at HMP Forest Bank
in May 2009 having been charged with offences related to motor car fraud. He
was still at Forest Bank in April 2010 when he was found guilty of the offences
with which he had been charged. He escaped from custody a few days later.
The man was re-arrested at the end of May 2010 and brought into HMP
Manchester. He was brought into the prison via Crown Court where he was
sentenced to nine and a half years imprisonment. He reported to a reception
nurse that he felt depressed about being back in custody, and also about the
sentence he had just received. He was unhappy about the prospect of a further
sentence, the recent suicide of his sister and also about missing his wife and
children. Reception staff opened an Assessment, Care in Custody and
Teamwork (ACCT1) plan and he was admitted to the prison’s healthcare unit
where he would have enhanced support from staff.
The following day, the man reported feeling very much better. He said that his
low mood the previous day was due to the upsetting events of that day. He
denied having any suicidal ideas and asked to move out of healthcare. Within a
few days the ACCT support was closed and he moved to E wing inner. (E wing
inner holds Manchester’s category A prisoners – the man was both a category
A prisoner and an escape-list prisoner.)
A second ACCT plan was put in place a few days later when the man reported
having suicidal thoughts because of marital difficulties. It remained open for the
rest of his life. The case reviews reflected some fluctuation in his mood and he
spent some time under constant supervision2 in healthcare.
The man’s mood appeared to begin to settle from around 13 June and he
returned to E wing. He still reported marital difficulties and was also anxious
about waiting for other family members to be cleared for visiting (more stringent
security clearance measures apply to visitors to category A and e-list
prisoners). His brother was imprisoned on another wing and, after his death,
reported that he had not been allowed to visit either. All his telephone contacts
had to be security cleared and these checks were completed within a few days
of his arrival into Manchester.
By 23 June, the night time ACCT checks had been reduced to once an hour. At
the 8.30pm check, the man seemed well and was watching television. When
the officer made the next check an hour later, the man was not in the main cell
area. The officer tapped on the door but, receiving no response, assumed that
he was using the toilet. He checked the other prisoners before returning to the
1 ACCT (Assessment, Care in Custody and Teamwork) is the process used for monitoring and
supporting prisoners deemed at risk of self-harm or suicide.
2 Constant supervision is the most intense form of support for a prisoner at risk of suicide or self
harm. A member of staff provided one-to-one supervision of the prisoner at all times of the
night and day.
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cell a few minutes later. The man was still out of sight and so the officer
summoned assistance. When staff went into the cell, the man was found
hanging in the toilet area. Staff attempted to resuscitate him and an ambulance
was summoned. Unfortunately, their efforts at resuscitation were unsuccessful.
I make three recommendations. One is about improving support for E wing
prisoners, who, as Category A prisoners, do not have access to all the support
mechanisms available to other prisoners. Another concerns the need for staff
to record any significant conversations with prisoners to ensure that other staff
members are aware of them. The third is about night time checks on E wing. I
also commend two members of staff for the way they communicated with the
man’s family after his death. The clinical reviewer makes 10 further
recommendations (as well as reiterating a recommendation made in my report).
5
THE INVESTIGATION PROCESS
1. The investigator in this case first visited HMP Manchester on 1 July 2010
when he met various staff from the prison’s safer custody team, two of the
prison’s family liaison officers and a representative from the Prison
Officers’ Association. He explained the nature and scope of the
investigation.
2. The investigator visited the man’s cell and was shown around the wing.
He was given a copy of the man’s prison and health records. Notices
were issued to staff and prisoners informing them about the investigation
and inviting them to contact the investigator if they wished to be involved
in the investigation.
3. The investigator subsequently interviewed 16 members of staff and one
prisoner. No other prisoners came forward in response to the notices
about the man’s death.
4. The investigator contacted the Coroner’s officer and a copy of this report
will be sent to the Coroner to assist his enquiries.
5. A clinical reviewer carried out a review of the man’s clinical care and
treatment on behalf of the local Primary Care Trust.
6. The Ombudsman’s Senior Family Liaison Officer wrote to the man’s wife,
mother and father to inform them of the Ombudsman’s role and
responsibility and to invite them to raise any concerns to be explored as
part of this investigation. The family raised no specific issues but did
express an interest in receiving my report. I hope that the report offers
further explanation into the events leading to the man’s death.
7. In accordance with the Prison and Probation Ombudsman’s operational
terms of reference, an advance draft of this report was disclosed to the
services in remit due to criticism made of the actions of a member of staff.
This is referred to again later on in this report which has now been fully
disclosed to all parties.
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HMP MANCHESTER
8. HMP Manchester is a category A (high security estate) prison located in
the centre of the city. In addition to its function as a category A prison,
Manchester also operates as a local prison serving the courts of the
Greater Manchester area. It holds up to 1,269 adult male prisoners on
remand, convicted and sentenced. The E wing inner section operates as
the self-contained unit for up to 53 category A and escape-list prisoners.
9. The National Offender Management Service (NOMS) publishes quarterly
performance ratings of prisons in England and Wales, with each prison
being assessed across a number of set indicators. Throughout the
2009/2010 operational year Manchester’s performance was deemed
“good” (this is the second highest possible rating).
10. HM Chief Inspector of Prisons (HMCIP) last carried out a full announced
inspection of Manchester in July 2009. In the introduction to the
inspection report the Chief Inspector wrote that:
“Unlike some of the other core locals, Manchester has always tried to
ensure that it can meet the needs of the great majority of its prisoners,
who could be found in any large local prison, while ensuring the
security necessary for category A prisoners. This inspection found that
still to be the case. The fact that category A prisoners were held on a
separate landing meant that security arrangements for the rest of the
prison did not intrude unduly on the regime. This did, however, create
a very claustrophobic and restricted regime on the category A landing.”
11. In considering support for prisoners at potential risk of self-harm, the Chief
Inspector found that:
“The comprehensive suicide prevention and self-harm strategy adopted
a holistic approach to support … assessment, care in custody and
teamwork (ACCT) documents … were reasonably well completed, but
case reviews were not sufficiently multi-disciplinary …”
12. Each prison in England and Wales is also monitored by an Independent
Monitoring Board (IMB) formed of volunteers from the local community.
IMB members have full access to every prisoner and all parts of the
prison. The Board produces an annual report, with the most recent
available for Manchester covering the period 1 March 2009 to 28 February
2010. The IMB commented in its report that staff at Manchester had
continued to meet targets and continued to maintain performance
expectations to a high standard despite the backdrop of efficiency savings
which had been required in recent years.
13. There have been 18 previous self-inflicted deaths at Manchester since the
Ombudsman began investigating all deaths in prisons in 2004. I have
found no particular similarities between the circumstances of those deaths
7
and that of the man’s. None of the previous deaths were of category A
prisoners.
8
KEY FINDINGS
14. The man was born in Rochdale in May 1981. He went to a school in
Cheshire but reported that he missed a lot of schooling and he left without
gaining qualifications. After finishing school he worked with his father in
labouring and landscaping jobs. He married at a young age and he and
his wife had three children and settled in a home in Stockport.
15. On 7 May 2009, the man was arrested and charged with several offences
of “conspiracy to convert criminal property” (the sale of stolen motor
vehicles). He was also charged with absconding from custody (he had
twice absconded from custody in 2002 while serving a nine month
sentence).
16. Having spent two days in police custody, the man was taken to HMP
Forest Bank in Manchester on 9 May. The prisoner reception process at
Forest Bank included an assessment of his mental and physical health
during which he reported no health problems. The following section of the
assessment form dealt with self-harming thoughts and behaviour. In
answer to several questions in that section he reported having no previous
history or current thoughts of acts of self-harm. The final section of the
assessment form was for the member of staff to make their own
assessment of his demeanour. He was described as “cheerful, co-
operative and polite”.
17. Within a few days of arriving at Forest Bank the man started working as a
wing cleaner. The entries in his records showed that he worked hard and
was polite and conformed to the rules. In due course he gained enhanced
privilege status. (Prisons provide a system of privileges that can be
granted to prisoners in addition to their minimum entitlement. This is the
Incentives and Earned Privileges scheme when privileges above the
minimum are earned by prisoners through good behaviour and
performance in work or education.)
18. In the middle of March 2010, the man’s sister committed suicide. He had
hoped to attend the funeral but was unable to do so as, on the day, Forest
Bank did not have sufficient staff available to escort him.
19. The man’s trial had also commenced in March 2010 at Crown Court. At
the end of April he was found guilty on various counts of fraud and
remanded back into custody pending sentencing.
20. At just after midnight on 2 May, the man called for help saying that he had
injured his ear. He was bleeding profusely so staff called an ambulance
for him to be transferred to outside hospital. While on the way to hospital,
the ambulance was intercepted by a masked gang who aided the man’s
escape.
21. The man remained at liberty for three weeks before being re-arrested in
the early hours of 28 May at an address near Southport in Merseyside.
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He was taken to a police station in Manchester where he was assessed by
a mental health nurse who thought that he seemed depressed. He was
taken from the police station to Crown Court where he was sentenced to
nine and a half years imprisonment further to his conviction the previous
month. From court, he was then taken to HMP Manchester where he
arrived at around 7.00pm.
22. When a prisoner is transferred between prisons or from one agency to
another, staff must complete a person escort record (PER) form on which
they list potential risk factors. In the man’s case the escorting staff
recorded that he said he had suicidal tendencies. Upon his arrival at
Manchester, the reception officer noted the entry on his PER form. Based
on that information, as well as the officer’s own observation of him
appearing to be “very low in mood”, the officer put ACCT support
measures in place.
23. The man was also assessed by a reception nurse who noted:
“… very upset and tearful during interview. Sentenced to 9 [years] 6
[months] doesn’t feel he will cope. States couldn’t cope with 12
[months] remand at Forest Bank. States feels very depressed at
thought of serving sentence, missing his children and wife … Informed
will be going back to [court] again and will be getting another 4 [years]
on top of his sentence due to his escape from Forest Bank. Informed
also that his sister hanged herself 3 weeks ago and he is not coping
with this …”
24. Following the reception process the man was moved to the prison’s
healthcare unit where a higher level of support could be provided. Later
that evening one of the healthcare nurses made a note in his ACCT plan
and clinical record of a lengthy conversation. The man repeated the
information he gave earlier about the prospect of a four year sentence on
top of the nine and a half year sentence he was already serving. He told
the nurse that he did not feel that he would be able to cope with such a
long sentence. When the nurse asked him if he had any plans to harm
himself, he replied that he did not want to kill himself. The nurse noted
that she encouraged him to focus on the positive aspects of his life.
25. Because the man had escaped from Forest Bank, he was classified as an
escape-list (e-list) prisoner, meaning a prisoner thought liable to try to
escape. He was also classified as a high-risk category A prisoner which
was linked to his escape, which was violent. Being an e-list prisoner
and/or a category A prisoner has a number of implications. At
Manchester, category A prisoners are held on E wing and so this was the
only wing where he could be held apart from healthcare. Another impact
was that all of his telephone calls would be monitored. In addition, more
comprehensive security checks were required before he could be allowed
any visitors. Pending completion of these security checks, category A
prisoners can be allowed closed visits with immediate family only at the
10
discretion of the Governor. (A closed visit is when the prisoner and visitor
are separated by a glass partition and cannot make physical contact.)
26. In the late morning of 29 May, the man had an ACCT assessment
interview with a senior nurse. (The ACCT process includes a detailed
assessment interview with a trained ACCT assessor to take place within
24 hours of the plan being put in place.) The senior nurse told my
investigator that her general practice is to carry out ACCT assessment
interviews on the second day after the person’s arrival into prison. This
allows them to “have a sleep and to settle down a little”. The senior nurse
said that when she met the man he said that he no longer needed
additional support. He said he had been upset the day before but this was
because he had only just been brought back into custody and had just
been sentenced. He said that he felt much better and had no intention of
harming himself. He also asked to move to a main prison wing as he felt
that being in healthcare was unhelpful.
27. The man spoke about his escape from custody, acknowledging that
cutting his ear had been part of the plan. His sister had committed suicide
a few weeks before but he had not been able to go to the funeral and so
he wanted to spend time with his family. The senior nurse told my
investigator that the assessment lasted around 30 to 45 minutes. He
made good eye contact and appeared open and honest with the things he
was saying.
28. An ACCT case review was held shortly after the assessment interview.
The senior nurse chaired the review and she was accompanied by a
Senior Officer (SO). The senior nurse told my investigator that the review
did not last long and that she and her colleague were in agreement that
the ACCT should be closed. She made an entry on the ACCT record to
say that, due to his demeanour, the support was to come to an end. She
also noted that he understood the support network available within the
prison and indicated that he would not hesitate to access that support if
needed. Not long afterwards he was discharged from healthcare to E
wing (the category A wing).
29. On 2 June, the man made several telephone calls to his family which were
monitored by Manchester’s security office. The security office sent a
report to E wing to say that the man had sounded unstable in some of the
conversations. On the same day, his mother telephoned the prison to say
that she was concerned about her son’s wellbeing. A senior officer made
an entry in the man’s records saying that they had spoken and, although
the man was “fed up”, he was getting on well with a number of the
prisoners and understood that support was available if he needed it. The
senior officer concluded that there was no need to re-open the ACCT plan.
30. A standard ACCT post closure review was held on 3 June. Staff members
at the review included one of the senior officers from the category A unit
(the first SO) and a Registered Mental Nurse from the mental health in-
reach team and employed by Manchester Mental Health and Social Care
11
Trust (the first RMN). The man said that he felt better about his situation
and some of his initial concerns had now been resolved, for instance being
able to telephone his family. He also said that he felt more settled on the
wing and knew some of the other prisoners there. The review panel were
content that the ACCT plan should remain closed.
31. Another of the senior officers from the category A unit (the second SO)
told my investigator that the man had two great concerns at this time. One
concern was that, being an e-list prisoner, he was still waiting for his
friends and family to be security cleared to allow them to visit. However,
his major concern was his relationship with his wife.
32. On the morning of 5 June, the first SO was told that the man wanted to
speak with him. The man came to the wing office and said that he could
not cope, his wife did not want anything to do with him and he was
contemplating taking his life. The first SO reminded him of reasons for
optimism, such as his children, but he persisted in saying that he wanted
to harm himself. The first SO re-opened the ACCT plan and called for an
ACCT assessor to come to see him.
33. The first Officer told my investigator that she is a trained ACCT assessor.
Before going to E wing, she spoke briefly with the first SO by telephone.
He told her that there was an immediate concern that the man might harm
himself. Based on what he had told her, the officer asked the second
RMN to assist with the ACCT immediate needs assessment in case he
needed to be moved to a safer cell (a cell designed to minimise as far as
possible any opportunities for self-harm through the use of ligatures). The
first officer and second RMN went to E wing.
34. The first SO and the man were in the wing office talking when the other
staff arrived. The first officer told my investigator that she explained the
ACCT process to the man and also clarified whether he wanted the first
SO to leave the room. The man said that he was content for both the first
SO and the second RMN to remain. He spoke about the issues in his life
which included his sister’s suicide, his escape from Forest Bank and the
problems in his marriage. He said that he felt better having spoken with
staff, but found that the most difficult part of the day was after 5.00pm
when he was alone to think about his issues. He mentioned feeling
isolated at this time of day.
35. Towards the end of the conversation, the first officer asked the man
whether he was still thinking of harming himself. He denied having such
thoughts but asked whether he could have a cell-mate. He was told that
he would not be allowed to share a cell while he remained a category A
and e-list prisoner. He agreed to approach staff for support if necessary,
or use the Samaritans telephone line.
36. The first officer said that the ACCT assessment interview “merged” into an
ACCT case review with the same four people remaining in the room. She
said that the entire process lasted around an hour and it seemed to work
12
well in terms of how open and co-operative the man had been. (The
ACCT process includes the setting of an appropriate level of interaction
that staff should have with the prisoner and in this case they were set at
three conversations during the day with hourly observations at night time.)
37. The first RMN reviewed the man on E wing on 7 June when she observed
that his mood appeared to be low. He mentioned having suicidal
thoughts, which he said escalated when he had contact with his wife.
However, he denied any intent to act on those thoughts and said that he
spoke to staff when there was a crisis. He also agreed to stop attempting
to contact his wife for a period of time to allow the situation with her to
settle. He mentioned having difficulty with his sleep pattern and the first
RMN noted that she would ask Manchester’s psychiatrist to consider
prescribing a sedative. The psychiatrist prescribed a sedative, Zopiclone,
that day. This was a seven day course of one 3.75 milligram tablet once
per day, to be taken in the evening.
38. The man’s next ACCT case review was held in the early afternoon of 8
June, chaired by the first SO. The man said that his wife was insistent that
their marriage was over and he saw “no light at the end of the tunnel”.
The notes of the review included him again agreeing that he needed “to
give it time for things to settle”. The second RMN was also at the review
and she made an entry in the man’s clinical records that he reported being
in a slightly better mood than when the ACCT plan was opened.
39. The second SO was also at the review on 8 June when the man spoke of
his concern over his relationship with his wife. Everyone present told him
that he should “take one day at a time”, which he accepted. The second
SO said that there was nothing about the man’s demeanour that day to
cause him to feel overly concerned for his welfare.
40. In addition to review meetings, an additional element of the ACCT process
is the construction of a CAREMAP. This should be a collaborative
process setting out each of the issues that are of concern to the prisoner
with a plan for how the issues will be addressed. In the man’s case issues
on his CAREMAP included contact with his family, to be removed from the
e-list and to deal with his threats (or thoughts) of self-harm.
41. At a consultation on 9 June with Manchester’s principal doctor, the man
reported having been in a low mood for the past three weeks. He
repeated that the contributory factors were his sister’s suicide, his
sentencing, escape and recapture, his expectation of an additional
sentence for the escape, and his marital difficulties. The doctor prescribed
a 28 day course of Citalopram Hydrobromide, an antidepressant
medication. He also prescribed a seven day course of 7.5 milligrams of
Zopiclone to be given at night. This was to be in addition to the day time
prescription written two days earlier. (The doctor’s entry in the prescription
chart was ambiguous and the first dose of the night time Zopiclone was
given to the man that afternoon. The following day the doctor rewrote the
prescription to make it clear that the medication was to be given at night.)
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42. On the morning of 10 June, the second SO chaired an unplanned, urgent
ACCT review. It was arranged at short notice following a report from the
prison’s security unit that the man had commented in a telephone call to
his mother that if “things didn’t go his way that day he would harm
himself”. The second SO told my investigator that the man’s greatest
concern was that his wife was not answering his telephone calls. He
reminded him about the support that was available, that is the prisoner
Listeners3, the Samaritans and wing staff. After the review the second SO
contacted the mental health in-reach team to ask them to come to see the
man. (This resulted in him being discussed in the clinical team meeting
leading to him being admitted to healthcare.)
43. That afternoon the man had a telephone conversation with his wife during
which they both became extremely distressed and he said that he
intended to take his life.
44. Manchester’s Safer Custody Manager was informed of the man’s threats
of suicide by the security unit and so he went to listen to a recording of the
telephone calls. He judged that the man was at high risk of harming
himself. He explained to my investigator that the Safer Custody Team’s
role includes co-ordinating the administrative aspects of the ACCT
process. The team also provide specific advice and guidance to staff but
do not generally become involved in managing prisoners which is the role
of wing staff.
45. On this occasion the Safer Custody Manager decided to have a closer
involvement and he attended the multi-disciplinary ACCT review for the
man that afternoon. The panel comprised a psychiatrist, three mental
health nurses, two discipline officers, the Safer Custody Manager and the
man. The Safer Custody Manager introduced himself to the man as the
Safer Custody Manager and asked him whether he was comfortable with
the number of people at the review. He replied that he was comfortable
with the number.
46. The review was chaired by a Registered General Nurse (RGN). The RGN
told my investigator that the man was very low in mood and tearful at
times. He spoke about his marriage saying that he and his wife had split
up on previous occasions before getting back together again. The
difference this time, he said, was that he had just been sentenced to nine
and a half years imprisonment and would also have additional time to
serve following his escape from Forest Bank. The consensus among the
review panel members was that he should be placed under constant
supervision in a gated cell.
47. The psychiatrist was also at the multi-disciplinary ACCT review on 10
June. He noted his impression that the man was suffering from an acute
3 Listeners are prisoners trained by the Samaritans to provide the same service as Samaritans
offer in the community.
14
adjustment disorder with suicidal intention (an adjustment disorder is a
state of distress following a significant life change or stressful life event).
The psychiatrist prescribed a different antidepressant to the one
prescribed the day before. The new prescription was for Mirtazapine and
was for a 28 day course of 15 milligrams per day.
48. The second RMN was on duty in healthcare and had a lengthy
conversation with the man that evening. It was a routine nursing
interaction unconnected with the ACCT process. The man spoke about
conversations with his wife and handed her three letters that he asked her
to read. Two of the letters were addressed to his wife and the other was
addressed to one of his brothers. He wrote in all the letters that he had
decided to take his life and explained why he had reached his decision.
The second RMN asked the man if he considered the letters to be suicide
letters but he said that that was not the case. Instead, he said that he had
written them as a way of expressing how he was feeling. He told her that
he would find it embarrassing if the letters were available for others to
read. In response, she scanned the letters as “attachments” to his
electronic health records. She noted the health record to say that the
letters were expressions of his feelings, but she did not note the nature of
the feelings he was expressing. She did not mention either the letters or
the conversation in the man’s ACCT record.
49. In her interview with the clinical reviewer, the second RMN said that her
conversation with the man would have been heard by the officer who was
carrying out constant supervision. She also said that she briefed the unit
manager. My investigator subsequently spoke by telephone to the second
RMN about her handover briefing to the unit manager. She said that the
handover would have taken place in the unit office and the unit manager
had probably been a nurse. However, she could not recall the name of
the unit manager, nor the content of their discussion.
50. The officer carrying out constant supervision that evening, 10 June, was
the second Officer. She made an entry in the man’s ACCT record alluding
to the contact between him and the second RMN, noting that she
considered that the man’s behaviour was manipulative. In discussion with
my investigator the officer explained that the man had spoken to several
nurses about the problems in his marriage, asking each for their opinion
about what he needed to do to re-establish the relationship. He would
then recite back to her (the second Officer) what each nurse had advised.
The Second Officer said that it seemed to her that the man was trying to
find out which of the nurses was most prepared to engage with him in
these conversations. She could not recall the man passing letters to the
econd RMN nor any discussion between them about any letters.
51. My investigator subsequently re-interviewed the second RMN later in the
investigation, this time in person. This second interview is referred to in
paragraphs 98 to 100 of this report.
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52. The man had another ACCT review on 11 June. One of the panel
members was the third RMN, who had also been at the review the
previous day. She told my investigator that the man was much better on
11 June compared to the day before. He said that a lot had happened to
him in the previous few months and he explained to the panel that his
suicidal thoughts were due to the shock of all the recent events in his life.
The record of the review includes his report that he felt more positive
about his life and was not suicidal at that particular time. The review panel
concluded that that constant supervision should cease. Instead his
observations should be reduced to five per hour with four “quality
interactions” (worthwhile conversations) by staff.
53. The psychiatrist was also at the ACCT review on 11 June and he
examined the man after the meeting ended. He found him to be “much
calmer and not so emotional”. He was thinking about his children and was
no longer suicidal. At the psychiatrist’s recommendation, the man left the
gated cell and was moved to a safer cell in healthcare.
54. A nurse made two lengthy entries in the man’s clinical records on the
evening of 11 June covering two conversations with him. He told her that
he did not feel safe in his current cell as he “could just wake in the night
and take his life”. He asked to move back to the gated cell where he
would have someone to talk with and someone to “save him if he did
anything”. The nurse contacted the duty Governor and later that night the
man was moved back to a gated cell and placed under constant
supervision again.
55. The RGN chaired the ACCT reviews on 12 and 13 June. She told my
investigator that, at the first of the reviews, the man showed a negative
attitude towards the healthcare unit and its staff. He said that he did not
feel he was getting any help but, when asked, could not explain what more
he expected. The panel decided that the man should remain in the gated
cell with constant supervision. She said that later that day the man asked
to speak with her again when he apologised for his earlier negative
attitude. He had had the chance to reflect on what had been discussed at
the case review and realised that he had to work with staff.
56. In her record of the ACCT case review on 13 June, the RGN noted the
man saying that he felt back to his normal self, having “lost his head for a
few days”. He said that he now felt okay and was no longer thinking of
suicide or self-harm. He added that his children were a reason to stop him
from harming himself. The review panel agreed that he could move out of
the gated cell and should be taken off constant supervision. Instead, he
was to be subject to intermittent checks/observation in a safer cell.
57. The third RMN was at the ACCT review on 13 June and made an entry in
the man’s clinical records saying that he had reported “feeling good and
back to his normal self”.
16
58. The psychiatrist reviewed the man on the morning of 14 June. He man
said that he felt well, was not suicidal and wanted to move out of
healthcare as soon as possible. The psychiatrist noted that the man’s
behaviour was “spontaneous and normal” and concluded that his
adjustment reaction was in full remission. The psychiatrist noted that he
would review the man again the following day and consider transferring
him to a standard prison wing.
59. At further ACCT case reviews on 14 and 15 June, the man reiterated that
he felt much better compared to when he first arrived in Manchester. At
the second review, staff concluded that his risk of harming himself was
low. The level of ACCT observations was reduced and during the day
staff were to observe him three times and have four quality interactions
with him. At night time he was to be observed once per hour. (His next
ACCT review was scheduled for 22 June.)
60. The third RMN had been at the ACCT review on 15 June after which she
made the following entry in the man’s clinical records:
“…he spoke at length about his current thoughts and feelings … says
he is no longer feeling low in mood … He was pleasant and polite, co-
operating fully with the review. He said he did not have any thoughts of
self-harm or suicide for the present time and said that he would
approach staff if he ever experienced these thoughts again. He said he
wanted to give his wife time to think and therefore would not be
contacting her in the near future. He spoke about his children being
positive influences in his life … A [multi-disciplinary team] decision has
been made for him to return to [E wing] … He is happy with this
decision and … said he will speak to his friends on the wing and
approach staff should he feel low in mood.”
61. In the afternoon of 15 June, the man was reviewed once more by the
psychiatrist further to his plan of care from the previous day. He noted
that the man spoke rationally and spontaneously. His mood was stable,
with no signs of mental illness or suicidal risk. The psychiatrist decided
that he was fit for discharge from healthcare and so he was discharged
back to E wing that afternoon. The psychiatrist also adjusted his dose of
Mirtazapine, doubling the dose to 30 milligrams per day.
62. The man was appointed a personal officer when he returned to E wing.
(Many prisons operate a personal officer scheme. Among other things,
the personal officer is a prisoner's first port of call if they have questions,
complaints or need advice.) The personal officer introduced herself to the
man on 16 June. This was their first meeting but she was aware of the
security unit reports that he had threatened to kill himself in telephone
conversations with his family. She said that their first meeting was fairly
brief as he was about to meet his lawyers. He mentioned that he had
applied for some emergency telephone credit but he did not know if the
money had been placed on his account. She told him that she would
17
check and she also took an application form with the list of his approved
visitors.
63. The personal officer said that she had quite a lot of contact with the man
over the following days. She described the processes for approving
visitors and telephone numbers for category A prisoners as laborious and
time consuming and she enquired how his applications were progressing.
She said that she kept him up to date on what was happening. He
accepted that they were slow processes but was anxious as he wanted
people to visit.
64. My investigator met one of the man’s brothers. He was also in HMP
Manchester at the time but on a different wing to his brother. He is a
prison Listener and he was accompanied by two members of the
Samaritans.
65. The man’s brother spoke in particular about the impact on his brother of
being a category A prisoner. He accepted that a greater level of security
checking must apply before category A prisoners can receive visitors, but
questioned why his brother could not have a closed visit while the security
checks were being completed. He said that his brother did not “see a
friendly face” in all the time he was in Manchester. He knew that prison
staff realised that his brother was at risk of harming himself and so he had
asked to visit him on E wing so that they could speak together. He said
that he was told that he could not do this.
66. At this point in the interview, one of the Samaritans mentioned that she
also had difficulty obtaining access to prisoners held on E wing, saying
that it had been many years since she had last been on that wing. She
said that she too asked to visit the man to tell him that his brother was
thinking about him but was refused permission.
67. My investigator asked the Safer Custody Manager, about Listener and
Samaritan support for prisoners on E wing and also enquired about the
man’s brother’s report that he had not been allowed to visit his brother.
The Safer Custody Manager explained that there were several reasons
why there were no trained Listeners on E wing. These included category
A prisoners not wanting to be Listeners as well as other prisoners not
meeting the security requirements. Also for security reasons, prisoners on
E wing have not previously had access to Listeners from other wings, and
have mainly been supported by using the Samaritans telephone. He said
that the prison is working on a protocol to ensure that Listener support can
be made available to E wing prisoners.
68. The Safer Custody Manager was previously unaware of the man’s
brother’s claim that he had not been allowed to visit his brother. (Nor did
Manchester have any record of such a request). The Safer Custody
Manager told my investigator that if he had been made aware of his
request, he was confident that arrangements could have been made
following consultation with the security department and perhaps with the
18
Samaritans. (Manchester further clarified that Samaritans would be
allowed onto the category A unit providing there was no operational
incident taking place at the time. However, historically, it has been very
unusual for category A prisoners to ask to speak with the Samaritans.
Manchester believed that that would explain why the Samaritan who
accompanied the man’s brother had not visited E wing inner for many
years. Manchester explained that a Samaritans telephone is available on
the wing, but was rarely used by category A prisoners.)
69. The man was reviewed by the first RMN on the morning of 18 June. Her
note of the consultation included that:
“… states that he feels better than he did this time last week and is
taking one day at a time. His social stressors remain unchanged and
he has not had any contact with his wife, he continues to be very
distressed by the situation and is clearly still ruminating on it despite
stating that he is giving his wife space. He is socialising on the unit and
fellow prisoners, and discipline staff report he appears more positive
within mood. He did question his prescribed antidepressant stating that
he feels they are not allowing him to think clearly and wants to stop
taking them, advised him to continue [taking] the antidepressant and
will arrange [an appointment with the psychiatrist] … at present denies
any thoughts of self harm or suicide.”
70. Later that morning, the personal officer made a note saying:
“… has been in a much better frame of mind since coming back onto
the unit a few days ago and has been out on association talking to
other prisoners as well as chatting to staff. He has also made steps
towards getting his family approved to visit. States he feels more
optimistic and settled.”
71. The first SO chaired the next ACCT case review on 22 June. He told my
investigator that the man seemed brighter and more focussed that day and
he asked for the ACCT plan to be closed. The review panel judged his
level of risk to be low, but they did not consider that the ACCT support
should be brought to an end. No change was made to the level of
interactions and observations, which meant that he continued to be
observed three times in the day with four quality interactions. At night time
he was to be observed once per hour. (As a category A prisoner, he was
in any case subject to hourly checks through the night.) The next case
review was scheduled for 5 July.
72. The first RMN was at the case review on 22 June. She made an entry in
the man’s clinical records to say that he had described himself as feeling
more settled in the prison and his mood was much better. He also
reported that he had stopped taking his antidepressant medication despite
her advice that he should continue with it. His records show that he had
refused the medication from 19 June onwards. He explained to her that
19
the medication gave him bad dreams so he was better off without it. She
noted that she would discuss the matter with the psychiatrist.
73. The personal officer was also at the ACCT case review on 22 June and
she too mentioned in discussion with my investigator that the man
reported feeling much better and asking for the ACCT plan to be closed.
74. The fourth staff representative at the ACCT case review that day was a
prison chaplain. The chaplain noted that the man was anxious to start
receiving visits from his family. She attempted to telephone the man’s
mother, but without success, so then telephoned one of his brothers. He
told her that the family were “all fine” and were attempting to arrange a
closed visit to the man. She passed this message to him.
75. The third Officer told my investigator that he was the cleaning officer on E
wing. (The cleaning officer supervises the prisoners who clean the wing
and who serve the meals.) He explained that his role meant that he was
always out on the landing so he had frequent contact with most prisoners.
He had a number of dealings with the man relating to clearance of
telephone numbers and visitors. He described the man as quiet compared
to other prisoners who had been on the wing for several months, but he
did not seem obviously upset at any time.
76. The third officer made an entry in the man’s ACCT record at just after
10.30pm on 22 June following a “short chat”. He noted that the man said
he would be staying on the ACCT plan for another week or so. He
accepted this even though he said he was ready for the plan to be closed.
The third officer concluded his note by noting that the man seemed in a
“bright mood”.
23 June
77. The personal officer made two entries in the man’s ACCT plan on 23
June. In the first entry, made at 10.10am, she noted that he had received
his canteen4, spoken by telephone to his family and looked more “upbeat”.
In her second entry, made at 11.00am, she noted that the man had
received notification of his prison release date and was very optimistic
saying that the time would go quickly. (His earliest release date,
dependant on parole, was calculated to be 7 June 2014, although he was
liable to have time added because of his escape from HMP Forest Bank.)
The personal officer told my investigator that the man had seemed to
improve in mood over the week or so that she knew him. They had
chatted about various things, including their respective children. He had
also begun to spend more time out of his cell on association, having made
some friends on the wing.
4 The word canteen refers to the prison shop. Prisoners are able to spend their own money on
items such as tobacco, toiletries and sweets. They submit their orders by completing canteen
sheets.
20
78. Other entries in the man’s ACCT plan made on 23 June might also
suggest that he was in good spirits that day. He asked for extra chips
when he collected his midday meal and he also collected extra food with
his evening meal.
79. The man made a great number of telephone calls to various family
members on 23 June. A number of his calls were unanswered, while in
others he spoke to different family members about completing relevant
paperwork so that they could visit. He made two calls asking for his
property to be brought to the prison. In other calls to family members, he
spoke about concern over what he understood to be on his wife’s
‘Facebook’ page. He made ten calls to his wife but none were answered
and generally he left no message. He left messages on three occasions,
telling his wife that he loved her and was upset about what he understood
was on ‘Facebook’.
80. The third Officer was on duty on the night of 23 June. At 8.30pm he made
an entry in the man’s records that he was sitting on his bed watching
football on television. The third Officer asked the man how he was and he
replied that he was okay. Around an hour later the third Officer went to
check him again. When he looked into the cell the man was not in the
main cell area and so the third Officer concluded that he must be in the
toilet. The third Officer tapped the cell door but the man did not respond.
The third Officer was not unduly concerned at that stage as a lot of
prisoners would be using the toilet/wash room at that time in the evening.
As all high-risk category A prisoners and e-list prisoners must be checked
hourly through the night, the third Officer first checked on other such
prisoners on the wing before returning to the cell a few minutes later.
There was still no sign of the man in the main cell area and so the third
Officer tapped the cell door again and then kicked it. There was still no
response and third Officer went to the wing office to get help. There was
no one in the wing office and so he radioed for assistance.
81. Another of Manchester’s senior officer told my investigator that he worked
in Manchester’s security unit and that evening was working as the duty
Assistant Night Orderly Officer (NOO)5. He confirmed that officers working
on the wings at night carry cell keys, which are contained in a sealed
pouch. The pouch should only be broken and a cell entered in the case of
an emergency. As the Assistant NOO, he carried open keys, but
restrictions still apply to unlocking cells at night time which usually include
the attendance of a dog and handler. That particular requirement can be
overridden by the overall officer in charge, the NOO.
82. The Assistant NOO said that as the man was not in his cell it was
assumed that he was in the toilet. The NOO had a key to open a separate
door leading to a service duct which allows restricted sight of the toilet
area via two Perspex windows spaced several feet apart. Looking into the
5 The Night Orderly Officer (NOO) is the person in operational charge of a prison at night time
and the Assistant NOO is second in charge.
21
toilet area, he thought that he could see a line (a ligature) running down
from the window bars. He shouted to his colleagues that he believed the
man was hanging. (My investigator went into the service duct and
confirmed for himself that visibility into the toilet area was poor.)
83. The NOO unlocked the cell door and staff went into the cell. When they
went into the toilet area they saw the man hanging from a ligature which
was tied to the window frame. One officer took hold of the man to relieve
the pressure from the ligature and another officer used his anti-ligature
knife to cut the ligature. The officers lowered the man to the ground,
removed the remnants of the ligature from his neck and tried to find a
pulse. A radio call was made for healthcare assistance (this was timed at
around 9.50pm) and the third Officer went to the wing office to collect first-
aid equipment. By the time he had returned to the cell with the equipment,
nursing staff had already arrived.
84. The emergency response nurse told my investigator that she was in the
healthcare unit when she heard the emergency call. She and another
nurse went to E wing, taking an emergency bag and a defibrillator6. The
emergency response nurse wrote in a statement that she examined the
man and found that his pupils were “fixed and dilated”; he had no pulse
and no signs of breathing. He was checked with the defibrillator which
advised that shock should not be given and cardio pulmonary resuscitation
(CPR) should commence. She said that she started to give chest
compressions while her colleague gave oxygen. They periodically
rechecked the man with the defibrillator but it repeated each time that no
shock be given and that CPR should continue.
85. An emergency ambulance was requested at the same time that healthcare
assistance was called for. The ambulance arrived at the prison at just
before 10.00pm and the crew, who were both ambulance technicians,
reached the cell five minutes later at 10.05pm. The emergency response
nurse said that the ambulance crew helped with the efforts to administer
CPR. The man was taken to the ambulance in a wheelchair while CPR
continued along the way. Ambulance technicians are not able to formally
pronounce death, but it seems that they telephoned for more senior
clinical advice and, at 11.15pm, the man was deemed to have died. The
ambulance was still at the prison at this time. It eventually left the prison
at 1.15am.
86. One of Manchester’s Roman Catholic chaplains told my investigator that
he was also one of the prison’s family liaison officers. The man was a
Roman Catholic and the chaplain said that he met him four or five times
during his time in Manchester. The man told the chaplain that his sister’s
death, and his recapture following his escape from Forest Bank, had both
affected him quite badly. The chaplain said that he had had a number of
telephone conversations with the man’s mother and aunt during the same
6 A defibrillator measures for presence of electrical activity in the heart and emits audible
instructions on management of the patient.
22
time, and both were worried that the man might take his life. The chaplain
tried to make the man understand the impact on his family if he were to
commit suicide. The chaplain thought that the man had begun to settle
and he was hoping to get some photographs of his children. The chaplain
said that he was telephoned at home on the evening of 23 June to be told
that the man had hanged himself. He went into the prison and blessed the
body.
87. The chaplain and one of Manchester’s Safer Custody Officers were asked
to visit the man’s family to break the news. The address they were given
turned out to be the home of his mother-in-law. From there they went on
to his home where they broke the news to the man wife.
88. The Safer Custody Officer said that after the man’s wife had been told
about her husband’s death, his concern began to focus on the man’s
brother. The Safer Custody Officer did not want the brother to find out
what had happened through hearing other prisoners shouting from their
cell windows. He and the chaplain therefore agreed that he would return
to the prison while the chaplain would visit the man’s mother. The Safer
Custody Officer said that when he got back to Manchester he woke the
man’s brother to tell him.
89. The chaplain told my investigator that, having broken the news to the
man’s wife, he went on to the man’s mother’s home while the Safer
Custody Officer returned to the prison. The chaplain told the mother of her
son’s death and remained in the house for about three hours. In due
course the man’s father and one of his brothers arrived and later his
grandparents came too. The chaplain said that when breaking the news
of a death he will try to judge whether the family would prefer him to leave
the home fairly soon or whether they prefer him to remain a little longer.
With the family, he judged that they would prefer that he stayed and he led
them in prayer.
90. A hot debrief meeting with staff was conducted by the duty Governor and
the care team were made available to them. Support was also offered to
other prisoners and in particular to the man’s brother.
91. Members of the family later came to the prison and met the Governor.
The man’s father and one of his brothers visited his cell. After that, the
chaplain took the family to the chapel where they lit candles. The family
were offered assistance with the funeral expenses.
92. All prison wings have post boxes into which prisoners post their letters.
When the E wing post box was emptied on the morning of 24 June, it
contained a letter written by the man. The letter was dated 23 June and
was timed 8.30pm (around the time prisoners would be locked in their cell
for the night on E wing). The letter was written to an acquaintance of the
man’s. It was optimistic in tone and asked the recipient to write back.
23
ISSUES
Manchester’s Category A unit
93. HMP Manchester’s primary purpose is as a local prison serving the courts
in the Greater Manchester area. In addition, it functions as a high security
prison holding 53 category A and e-list prisoners who are held on E wing
inner. E wing inner is a self-contained unit which has a separate and more
restricted regime compared to the rest of the prison.
94. There were several implications for the man through being both a category
A prisoner and e-list prisoner. One of these was that, even by the time of
his death 26 days after he was taken to HMP Manchester, he had yet to
receive a family visit. Although his list of telephone contacts had been
cleared within a few days of his arrival into Manchester, the people on his
visiting list were still being security vetted (as I have explained, a higher
level of vetting is required for visitors to category A and e-list prisoners).
Had the man submitted an application to receive closed visits from
members of his immediate family, this could have been granted at the
Governor’s discretion. Information about visiting arrangements, including
the facility to request closed visits, is contained in a booklet issued to
prisoners during the prison induction process. In addition, from a
discussion between a member of the chaplaincy team and one of the
man’s brothers, it also seems the family might well have been aware of the
facility.
95. Another implication for the man from being a category A and e-list prisoner
was that his brother, who was based on another wing, was apparently told
that he could not visit him. The brother apparently asked if he could do so
as he was aware that the man was potentially at risk of harming himself. I
understand from the evidence given by the Safer Custody Manager that
arrangements could have been made, even though that would have
involved input from the security department. It is disappointing that,
despite two periods under ACCT monitoring, no consideration was given
to arranging for the brothers to meet.
96. My investigator also asked the Safer Custody Manager about access to
Listeners for category A and e-list prisoners. The provision of Listeners is
widespread throughout the prison estate and they provide valuable
support to prisoners who are at risk of harming themselves. I am
concerned that there are nevertheless no trained Listeners on E wing. I
understand that this is mainly because of the security implications
surrounding category A prisoners. I am pleased to learn from the Safer
Custody Manager that the prison is developing a protocol by which
Listeners based on other wings can be safely brought to E wing when they
are needed.
24
97. The clinical reviewer also considers that the man would have benefited
from having access to a Listener. (Manchester has commented that the
man had previously worked as a Listener so was aware of the scheme.
However, he did not ask to speak with a Listener. Manchester also
commented that the man was informed that the Samaritans telephone was
available.)
I recommend that, if not yet in place, the Governor should ensure
that Listener support is made available to E wing prisoners without
further delay.
The letters given to the second RMN
98. On 10 June, the man gave three letters to the second RMN in the course
of a routine nursing contact. Two letters were addressed to his wife and
one to a brother. In all, the man wrote about his intention to take his life
and the reasons behind his decision. When the second RMN asked him if
they were suicide letters he denied that to be the case, saying that he had
written them as a way of expressing his feelings. He added that he would
find it embarrassing if the letters were to be seen by a wider audience and
so he asked for them to be kept out of his ACCT plan. The second RMN
agreed to his request. She said that she briefed the wing manager, but
she could not recall who this was that evening. She made no entry in the
man’s ACCT plan about the letters or of their conversation. In his clinical
record, the second RMN noted that the man had handed her some letters
which he explained were written to express his feelings, but she included
only that stark detail.
99. Staff will often need to consider carefully how they should deal with
matters that prisoners divulge in confidence. If the prisoner’s request for
confidentiality is not honoured, it might deter them from ever again
disclosing potentially important information. However, staff also have a
duty to keep prisoners safe especially those, such as the man, who are
being supported by ACCT monitoring. I consider that it would have been
possible for the second RMN to have noted in the ACCT form, and in the
man’s clinical records, the essence of what he had written in his letters
together with his explanation that this was not a real suicide plan but
merely capturing his thoughts. Of course she would have needed to
explain to the man what she intended to do.
100. As indicated earlier on in this report, an advance draft was disclosed to the
services in remit due to the criticism made of the actions of the second
RMN. During a second interview with my investigator, the second RMN
reiterated what she had said previously about the man wanting his letters
to remain private and that he confirmed to her that the letters were not
statements of intent to self-harm, but were instead an expression of his
thoughts. While I recognise the potential dilemma for her, I remain firmly
of the view that she should have made an entry in his ACCT form to reflect
the substance of their conversation.
25
I recommend that the Governor and Head of Healthcare remind all
staff about the importance of recording significant conversations and
events in ACCT plans and in the clinical records.
Frequency of ACCT conversations and observations
101. Prison Service Order (PSO) 2700 deals with suicide and self-harm
prevention and it includes guidance on the ACCT process. This includes
some guidance on the setting of conversations and observations. PSO
2700 gives no examples however of situations where any particular level
of interaction might be applicable. Nor is such guidance contained in the
ACCT training that all staff undertake. Guidance is not given because
staff are expected to deal with prisoners as individuals and tailor the
support plan to the individual and their prevailing circumstances.
102. Deciding on what would appear to be an appropriate level of interaction in
the man’s case was therefore a matter for the judgement of the review
panels who sat to consider his needs over the period of time he was
subject to ACCT monitoring and support. I note in passing that the
reviews were held as often as they were required and that an additional
review was called at short notice on one occasion. I am also pleased to
see that each review was attended by various multi disciplinary staff and
that the man was present on every occasion.
103. The final ACCT case review was held on 22 June, the day before the
man’s death. Based upon the written record of the review and the oral
evidence of the staff to whom my investigator spoke, the man’s mood
seemed to have lifted. He said that he was feeling much better and asked
for the ACCT plan to be closed. The panel members accepted that the
man’s mood had lifted but they told him they would keep the ACCT plan
open for the time being. By that time, the level of interactions with him
was three observations and four quality interactions during the day. At
night time he was to be observed once per hour. (As a high-risk category
A prisoner and e-list prisoner, he was in any case subject to hourly
observations at night.)
104. Having mentioned all of the above, I consider, on balance, that the man
could have been subject to more frequent observations, certainly at night
time. He had said previously that the most difficult time was when he was
locked in his cell and alone with his thoughts. In addition, it is clear that he
was still trying to come to terms with all that had happened to him in the
previous few weeks. This included his marital difficulties and he was also
still waiting for clearance for family members to start visiting him. If he
been subject to night time observations at a greater frequency than one
per hour, that would have clearly separated him from the other prisoners
on E wing in the minds of the staff. He might also have found this
additional support reassuring. While I make no criticism of the decision
making of the review panel, the Governor will no doubt wish to reflect upon
any lessons that can be learned from the man’s specific circumstances.
26
The delay before staff went into the man’s cell on 23 June
105. When the third Officer checked the man at 8.30pm, he was sitting on his
bed watching football. At the time of the next check an hour later, the third
Officer assumed that the man was using the wash basin/toilet as he was
not in the main cell area. He did not respond to taps on the door and the
third Officer decided to leave him while he checked the rest of the wing.
When the third Officer returned, the man could still not be seen. This time
the NOO was called, leading on to the discovery that the man was
hanging. It seems likely that around ten minutes might have elapsed from
the time of the third Officer’s first check to the point that staff cut the
ligature.
106. As already discussed, the man was subject to hourly ACCT checks
through the night. He would in any case have been subject to hourly
checks through the night as a security measure given that he was a
category A prisoner. I think that it rather defeats the purpose of these
checks if officers neither observe nor obtain a response from the prisoner
at the exact time of the check. I consider that the third Officer should have
persisted in attempting to obtain a response from the man when he made
the check at 9.30pm and should have called for assistance without delay
once it was obvious that he was not responding.
I recommend that the Governor should consider revising the
instructions to staff when conducting night-time checks on category
A prisoners. If the prisoner cannot be seen, the officer should
request a verbal response before moving on.
Confirming that the man had died
107. The clinical reviewer found that healthcare staff made appropriate efforts
to try to resuscitate the man. However, my investigator also spoke with
the Legal Services Co-ordinator from the Ambulance Trust to ask about
the status of an ambulance technician. The Co-ordinator explained that
ambulance technicians are able to carry out most of the procedures
carried out by paramedics, but they cannot intubate or cannulate patients
(intubation and cannulation are the insertion of tubes and lines into the
body). The Co-ordinator said that the ambulance trust does not employ a
sufficient number of paramedics to ensure that all emergency response
vehicles are staffed by such professionals. When technicians require
greater expertise, then paramedics are called for. She added that the
evidence was that the man’s care was not compromised either through the
presence of ambulance technicians or the time it took before the
ambulance left the prison.
The delay before the ambulance departed
108. The man had a previous history from long before of absconding from
prisons. He also had a much more recent history of a violent escape from
a closed prison. He was in HMP Forest Bank when he deliberately cut his
27
ear. An ambulance was called to the prison to transfer him to outside
hospital. While on the way to hospital the ambulance was intercepted by
an armed gang, affecting his escape. He remained at liberty for three
weeks before being re-arrested at the end of May 2010. As a result he
was classed as a category A (high risk) prisoner and an e-list prisoner.
For all such prisoners, greater levels of security arrangement are put in
place. Such arrangements include a requirement upon the
accommodating prison to obtain formal sanction from Prison Service
headquarters before transferring the prisoner to hospital. In his case this
took some time to achieve.
109. Having sought more senior clinical advice, the ambulance technicians
deemed at 11.15pm that the man was dead. In reality it would seem his
death actually occurred much earlier in which case his care would not
have been compromised through the delay in the departure of the
ambulance. My investigator spoke with the deputy Governor about this
matter. The deputy Governor said that the departure of the emergency
vehicle would not have been delayed had there been any prospect that the
man’s life could have been saved.
110. My investigator spoke with Manchester’s deputy Governor about the delay
before the departure of the ambulance on the night of the man’s death.
He said that ordinarily authorisation from Prison Service headquarters
must be obtained when transferring a prisoner such as the man, who was
a category A prisoner and also an e-list prisoner with a history of violent
escape. In addition, the ambulance crew were reluctant to take him
without an escort given his previous violent escape from an ambulance. It
therefore took time to obtain authorisation for the transfer. He assured the
investigator that, had there been any prospect of saving the man’s life by
taking him to hospital, the ambulance would have been allowed to leave
immediately whilst the necessary authorisation and security issues were
actively underway. I accept his assurance on this matter.
Matters following the man’s death
111. Manchester’s Roman Catholic chaplain, with the role of prison family
liaison officer, was at home on the evening of 23 June when he was
contacted by the prison and told of the man’s death. The chaplain went
into the prison and blessed the body. After that the chaplain, in company
with the Safer Custody Officer, visited the man’s family to break the news.
(The chaplain had previously spoken by telephone with the man’s mother
and aunt whilst was alive.) Both were conscious of the danger that the
man’s brother might hear the news of the man’s death from other
prisoners and so the Safer Custody Officer returned to the prison to speak
to him. The chaplain then remained with the family for the next several
hours during which time he led them in prayer. I consider that the chaplain
and Safer Custody Officer demonstrated the very best of practice in
carrying out this important and sensitive role.
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Findings from the clinical reviewer
112. The clinical reviewer found that the psychiatrist’s diagnosis that the man
was suffering an adjustment disorder was appropriate. However, the
reviewer considered that it was too early for the psychiatrist to conclude on
14 June that the condition was then in full remission. The reviewer also
found that the psychiatrist did not appear to take a systematic or thorough
exploration of symptoms that might have been indicative of depression.
113. The clinical reviewer considered that prescribing anti-depressants was
reasonable, especially as the prescription was not made in isolation from
other approaches. The reviewer did not believe that the man’s mental
health deteriorated when he stopped taking his anti-depressants.
114. The clinical reviewer identified a number of omissions in the completion of
the man’s prescription charts, other healthcare documents and ACCT
plans. He also identified omissions in the process for checking of
emergency healthcare equipment.
115. At interview with nursing staff, the clinical reviewer identified
inconsistencies in the support offered to staff following the man’s death.
Both of the nurses involved in the attempts to resuscitate the man
attended the hot debrief on the morning after his death but neither
attended the subsequent cold debrief. One was absent because she was
on holiday at the time but the other was not invited. A third nurse who had
significant involvement with the man was not invited to the cold debrief,
nor offered support from the care team. In addition, she was dissatisfied
with the way in which she was informed of the man’s death.
116. The clinical review makes 10 recommendations, which I summarise below.
These were directed to the Governor and Head of Healthcare and
responses following consideration at draft stage are contained in italics
below each recommendation.
The Head of Healthcare should, in consultation with the GP service,
ensure that locum doctors are adequately inducted into their role at
Manchester, particularly with regard to the ACCT process.
Response: Recommendation accepted. The ACCT procedures are written
into the GP Locum pack provided to the member of staff. Due to the transient
nature of locum doctor provision, many of whom attend the prison for just one
day, it would not be feasible to give all the locums full ACCT induction. To
ensure the risk is managed all locum GPs are escorted by an ACCT trained
healthcare member of staff for guidance and support.
The Head of Healthcare should explore with the in-patient and mental
health in-reach teams, potential problems in the way the teams work
together and the extent to which this influences clinical practice.
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Response: Recommendation accepted. Systems are now in place to ensure
admission and discharge procedures and assessments are jointly managed.
The Head of Healthcare should ensure that appropriate clinical
supervision is provided for healthcare staff at Manchester.
Response: Recommendation accepted. On a monthly basis healthcare staff
have the opportunity to book in for individual clinical supervision sessions. An
e-mail has been sent to all staff reminding them of the benefits of attending
clinical supervision. Target for completion: 31 December 2011.
Training should be organised for mental health in-reach team staff in
the completion of the standard assessment form in use by their team.
Response: Recommendation accepted. Training will be given by the
Manchester Mental Health and Social Care Trust. Target for completion: 31
December 2011.
The Head of Healthcare should ensure that the allergies/sensitivities
section of prescription charts is completed. Compliance should be
monitored as part of a regular audit.
Response: Recommendation accepted. This will be implemented. It is also
incorporated into the electronic system. Target for completion: 31 December
2011.
There should be regular audit of the quality of clinical record
keeping, ensuring that standards reflect the guidance of the relevant
professional bodies. Healthcare staff taking part in the ACCT
process should record significant developments in the
corresponding clinical record.
Response: Recommendation accepted. Clinical record keeping forms part of
the annual audit calendar. Guidance will be published on cross referencing
between the ACCT documentation and the corresponding clinical record.
Target for completion: 31 December 2011.
The Head of Healthcare should ensure that the quality of record-
keeping by healthcare staff in ACCT plans is audited regularly.
Response: Recommendation accepted. The ACCT process is not a clinical
intervention and as such all ACCT documents are regularly checked by prison
managers to ensure they are of high quality. This provides assurances that
ACCT entries are of a good standard and reflect appropriate management of
the identified issues. This practice applies to all areas of the establishment
including Healthcare.
The Head of Healthcare should review and monitor the process for
obtaining previous prison or community records for prisoners
arriving at Manchester.
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Response: Recommendation accepted. All records where an identified GP is
known are requested as a matter of standard practice. All prisons are now on
System One so any prisoners received in to Manchester from other
establishments are requested and sent electronically. Target for completion:
31 December 2011.
The Head of Healthcare should liaise with the Ambulance Trust to
determine the need for any particular arrangements on the expertise
of ambulance personnel called when a prisoner is found hanging at
Manchester.
Response: Recommendation accepted. A policy is now in place with the
Ambulance Service.
The reliability of the system for identifying and approaching staff
affected by serious incidents should be reviewed.
Response: Recommendation accepted. The process by which staff are
identified and supported post incident will be reviewed. Target for completion:
31 December 2011.
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CONCLUSION
117. The man had been in Manchester for a little under a month when he took
his life. He experienced many stressful events around and just before this
time. They included the suicide of his sister, being found guilty on charges
of conspiracy to convert criminal property following a lengthy trial, his
escape from prison and recapture and being sentenced to nine and a half
years imprisonment with a likely additional sentence for his escape from
prison.
118. However, by all accounts, the most significant single factor for the man
was the difficulty in his marriage. He spoke about these difficulties at
ACCT reviews and in consultations with nurses. Staff advised him to give
his wife time and to try to take each day of his sentence at a time. In
principle he appeared to accept that he needed to do so. However,
despite his apparent acceptance, it is clear that he found it difficult to put
the advice into practice. As a result there were times when his mood
swung quite markedly in a brief period.
119. By 23 June, the man was undoubtedly more settled than he had
previously been. However, he was still being supported through the ACCT
process, even though he was by then on a low level of observations and
interactions. It remains very unclear from this investigation whether he
truly intended to take his life when he did. He had written several
apparent suicide letters to family members several weeks before his
death, but voluntarily handed them to a nurse. In discussion with the
nurse he denied that they were suicide letters, he said, instead, that he
found it helpful to have expressed some of his thoughts on paper.
120. On the day of his death, less than one hour appears to have elapsed
between the man posting a letter to an acquaintance inviting a response
and then him being found hanging in his cell. This investigation has found
that he was having considerable difficulty accepting the recent events that
had happened to him. While I make no criticism of the actions of staff, I do
consider that lessons could be learned in respect of the support available
to at risk Category A prisoners at Manchester.
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RECOMMENDATIONS
The following recommendations were made in the draft report. The Service
responses are included in italics following each recommendation:
1. I recommend that if not yet in place, the Governor should ensure that
Listener support is made available to E wing prisoners without further
delay.
Prison Service response: Recommendation accepted. A protocol is currently
being developed to provide listener support to the Category A Unit. Target for
completion: 31 December 2011.
2. I recommend that the Governor and Head of Healthcare remind all staff
about the importance of recording significant conversations and events in
ACCT plans and in the clinical records.
Prison Service response: Recommendation accepted. Guidance will be sent
to staff regarding the recording of significant conversations and events in
ACCT plans and in the clinical records. Target for completion: 31 December
2011.
3. I recommend that the Governor should consider revising the instructions to
staff when conducting night-time checks on category A prisoners. If the
prisoner is in the toilet, the officer should request an oral response before
moving on.
Prison Service response: Recommendation accepted. The instructions to
night staff on the category A Unit will be reviewed. Target for completion: 31
December 2011.
COMMENDATIONS
1. I commend the family liaison team, the chaplain and Safer Custody
Officer, for the thoughtful and sensitive way in which they dealt with the
man’s family following his death.
Prison Service response: Formal recognition will be given to the officer and
chaplain for this family liaison work.
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