Individual at Lincoln

Investigation into the circumstances surrounding the
death of a man
at HMP Lincoln on 13 June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2011
Ashley House, 2 Monck Street, London SW1P 2BQ Tel: 020 7035 2876 Fax: 020 7035 2860
E-mail: mail@ppo.gov.uk www.ppo.gov.uk
This is a report into the death of a man at HMP Lincoln on 13 June 2008. He was
found by staff, hanging in his cell in E wing, the vulnerable persons unit. He was 39
years old.
This is the second time that my office has investigated a death in this family which
must be very difficult for them to bear. I extend my sincere condolences to the man’s
family as well as others who have been affected by his death. I also apologise for
the length of time it has taken for this report to have been completed and the added
distress this may have caused.
This investigation was originally opened by one of my colleagues; who visited the
prison and completed a number of interviews. However, he retired before finishing
the investigation and it was reallocated to another investigator, in February 2010.
A review of the clinical care and treatment the man received was commissioned and
carried out by Dr A of Lincolnshire Primary Care Trust. I am grateful to him for
completing this review.
I would also like to thank the Governor and staff at Lincoln, as well as Detective
Inspector G and Detective Sergeant K of Lincolnshire Police, for their assistance
during the course of this investigation.
The man was accustomed to prison life and was recalled to Lincoln on 1 August
2007, after failing to keep in touch with his probation officer. He was moved to the
vulnerable prisoners unit after getting into debt on his residential wing. He got into
debts and felt pressured by other prisoners. These events may have been impacted
on the man’s thoughts when he took his own life. He was being monitored by the
prisons suicide support measures and should have been moved to a safer cell.
My investigation was delayed whilst allegations about the conduct of a prison officer
were considered. Neither I nor the prison, nor the police have found any substantive
evidence that the officer’s conduct was the cause of the man’s death. However,
there is circumstantial evidence that indicates the officer’s actions might have led to
the man being bullied by other prisoners.
I make ten recommendations. Several concern the management of prisoners
subject to self-harm and suicide prevention procedures. The investigation has
revealed failings in the completion of the documents relating to such procedures as
well as shortcomings in the staffing and training of staff. I also recommend that staff
seek medical assessments if a prisoner’s physical or mental condition gives cause
for concern over a period of time and that staff consider nicotine replacement if a
prisoner at risk is on a basic regime, with limited access to tobacco. Staff expressed
confusion about the protocol for calling an ambulance in an emergency and some
were dissatisfied with the debrief meetings held. Accordingly, I make
recommendations on these matters as well as the need for prompt resolution of
complaints by prisoners.
At the draft report stage, the man’s family provided detailed feedback. We are very
grateful for their contribution to the investigation. Some changes in the report have
been made to reflect their comments. The man’s family continue to have
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considerable concerns about the level of care he received while in prison and think
that his death could have been prevented.
Jane Webb
Acting Prisons and Probation Ombudsman September 2010
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CONTENTS
Summary
The Investigation Process
HMP Lincoln
Glossary
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was recalled to prison on 1 August 2007, following a breach of his licence.
On reception at prison, he had a health screen in which he told staff that he had no
previous mental health treatment but that he had a history of drug and alcohol
misuse. He was prescribed mirtazapine, an antidepressant and put on a detoxifying,
reducing dosage of Subutex to prevent withdrawal symptoms.
The man was used to prison life and quickly settled into the regime. However, he
started to deal in drugs and tobacco which resulted in debt, which he could not pay.
After he was refused a move to another wing, the man harmed himself by cutting his
wrists. He was subsequently moved to the vulnerable prisoners’ unit.
Again, the man settled in at first and was promoted to enhanced level on the
Incentives and Earned Privileges scheme (IEP). However, he again became
involved in dealing Subutex and tobacco, which resulted in further debt. He then
started bullying other prisoners and was made subject to the anti-bullying procedures
as well as being placed on the basic IEP level. The man clearly found this difficult
and appealed against it. At the time, he felt threatened by those to whom he owed
money and from 9 June 2008, until his death he stayed in his cell and did not take
part in association.
On 12 June 2008, the man asked to move to the segregation unit because of his fear
of the prisoners who were threatening him. This was not approved. He
subsequently harmed himself by cutting his arms and was made subject to the
suicide and self-harm prevention procedures. Throughout 12 June 2008, the man
was described as acting in a “paranoid” way and barricading himself into his cell. He
continued to make allegations of bullying against prisoners but he refused to sign the
statement to this effect unless he was allowed to move to the segregation unit.
Governors then said he could not go to the segregation unit given that he was being
monitored for his own safety and said that he would be more isolated in the unit.
On the morning of 13 June 2008, an officer was checking prisoners subject to
suicide monitoring procedures when she found the man in his cell, hanging from the
window bars by a ligature. A code 1 emergency call was made and an ambulance
called. The man had barricaded his cell door, so staff had to collect a special key to
unlock the doors outwards before they could assist him. As the cell was on the
ground floor a senior officer went outside and cut the ligature. Eventually, staff
gained access and pulled the man’s body out of the cell. Resuscitation attempts
were made by healthcare staff and paramedics but he was pronounced dead at
8.41am. Debriefs were held for staff and prisoners subject to suicide prevention
monitoring were reviewed. Prison staff contacted the man’s designated next of kin.
I make ten recommendations. Several relate to the completion of suicide and self
harm monitoring documents as well as the provision and training of staff to
undertake the procedures. Additional recommendations cover dealing promptly with
complaints, obtaining medical assessments if a prisoner’s physical or mental health
appears to deteriorate, considering nicotine replacement if a prisoner at risk is on
basic regime and procedures to be followed in the event of serious incidents of self-
harm or suicide.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 18 June 2008, when the investigator Mr A,
issued notices announcing the investigation to staff and prisoners. The
notices included an invitation to those who wished to submit information
related to the man’s death to make themselves known to the investigator. A
number of prisoners came forward and were subsequently interviewed. Mr A
met the Governor, deputy governor and the chairs of the Independent
Monitoring Board (IMB) and Prison Officers’ Association.
2. Mr A was given access to the man’s prison files, including the medical
records. He later returned to Lincoln on 7 and 8 and 14 August 2008 and 2
September 2008 to interview staff and prisoners.
3. A clinical review of the man’s healthcare whilst he was in custody was carried
out by Dr A on behalf of Lincolnshire Primary Care Trust.
4. One of my Family Liaison Officers, (FLO’s) Ms B, contacted the man’s ex
wife, his father and his sister to advise them of the investigation and invite
them to raise any matters they would like to be addressed. Mr A and Ms B
subsequently visited the man’s sister and his ex wife. They raised a number
of concerns for my investigation to consider. I hope that my report addresses
their concerns.
5. Mr A was unable to complete the investigation as he retired from the office. It
was re-allocated to another investigator, Ms C, on 1 February 2010. Ms C
reviewed the documents. She also visited Lincoln prison and obtained further
information, including Assessment, Care in Custody and Throughcare (ACCT)
documents and other records relating to the man’s time in custody. Ms C also
met with Detective Sergeant G and Detective Inspector K.
6. Ms C re-interviewed an officer previously interviewed by Mr A. Throughout
the investigation, she liaised with and met with Lincolnshire Police about their
investigation into alleged offences by a prison officer who worked on the wing
where the man died. Detective Sergeant K and Detective Inspector G shared
police statements and a letter that the man wrote shortly before his death.
The investigation into the behaviour of the officer and subsequent police
enquiries resulted in a delay to the completion of this report.
7. On 11 March 2010, two of my family liaison officers, Ms D and Ms C visited
the man’s sister at her home, in response to her request. They discussed her
original concerns and noted further issues. His sister had heard that a prison
officer who had worked on the man’s wing at Lincoln had been dismissed
from the Prison Service for supplying drugs and mobile telephones and
bullying prisoners. She believed that this officer had impacted on the man’s
state of mind when he took his life and wanted the investigation to clarify any
involvement and what the prison did about this. The man’s sister was aware
that a colleague had reported the officer to the prison security department.
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8. The man’s sister also wanted to know why her brother had been prescribed
mirtazapine. She understood that in the first few weeks of taking it there was
a higher risk of suicide.
Post mortem and toxicology reports
9. A post mortem was carried out by Professor G, a forensic pathologist. A full
copy of the report is attached as an annex to this report. The summary of his
findings were that there was no evidence of natural disease that had
contributed to the man’s death and no marks that would raise suspicion about
the man having been a victim to violent assault, or having been restrained
against his will.
10. The toxicology report informed that there was nothing suspicious in the man’s
blood or urine.
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HMP LINCOLN
11. HMP Lincoln was built in 1872 and is a category B prison holding male
prisoners. New prisoners are risk assessed and given a category based on
their offence and the risk that they pose to the public should they escape.
There are four categories: A, B, C and D, with category A prisoners being the
most dangerous. Category B are prisoners for whom the highest security
conditions are not necessary but for whom escape must be made very
difficult. The prison’s design is typical of the times, with galleried wings
spreading out from a central core. All cells have integral sanitation. It serves
the nearby courts of Lincolnshire, Nottinghamshire and Humberside. The
prison holds remand prisoners and those serving short sentences or waiting
to be moved to another prison. It holds a maximum of 738 men, which
includes a small number of remanded young offenders.
12. There are four main residential units. A wing consists of the first night centre
and holds prisoners on induction. B wing holds sentenced prisoners and C
wing holds remand and convicted prisoners. D wing is the segregation unit
and E wing is the vulnerable persons unit. J wing holds prisoners on short
duration drug treatment programmes.
13. Healthcare at Lincoln is commissioned by NHS Lincolnshire and is provided
by Lincolnshire Community Health Services. There is inpatient
accommodation.
14. The former Chief Inspector of Prisons completed an inspection of Lincoln in
December 2007. She said of the prison, in general terms:
“Lincoln prison has gone through a difficult period, but this inspection
found that normality had returned, with both accommodation and staff
morale repaired following the disturbances. In effect, the prison had
successfully turned a particularly unfortunate page in its history. The new
governor still has plenty of work ahead to develop a fully effective local
prison, particularly given the poverty of purposeful activity, but there are
some solid foundations now in place.”
In respect of E wing, the former Chief Inspector of Prisons commented as
follows:
“During the previous 10 months, 128 bullying information reports had been
received. … The most significant issue to have emerged was the
disproportionate number of bullying incidents (56) alleged to have
occurred on E wing.
The strategy to address bullying, and its consequences for both victims
and perpetrators, was acknowledged to be inadequate, and a revised
strategy was due to be launched shortly after the inspection. …
Allegations of bullying were followed up with some form of investigation,
although this was frequently frustrated by prisoner’s unwillingness to
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appear as witnesses. … There had been no formal training of staff in
bullying matters.”
The former Chief Inspector of Prisons said of the vulnerable prisoners’ unit:
“The sex offenders alleged that others on the wing operated in a bullying
fashion towards them. There was no compact to regulate expected
behaviour, and the consistent involvement of staff in prisoners’ lives was
ineffective.
“There was no clear protocol on how to decide whether a prisoner could
be accepted onto the wing.” … Between 40% and 50% of the bullying
incidents reported each month emanated from E wing, and this had been
the case for several months before the inspection. However, at the time of
the inspection there were no prisoners on E wing on the basic level of the
incentives and earned privileges (IEP) scheme, and none were being
monitored under the anti bullying strategy.
“In group discussions, the vulnerable prisoners were the most negative
group in regard to feeling that they were ignored by the establishment.
They were the most critical of the personal officer scheme, and wing files
examined on this wing showed the least evidence of entries made by staff
about prisoners. On some days during the inspection, none of the staff on
duty on E wing were regulars.”
15. The former Chief Inspector of Prisons made three recommendations:
• Clear protocols should be drawn up to establish which prisoners should
be admitted onto E wing.
• There should be regular staff on E wing.
• The personal officer scheme on E wing should be re-launched.
Independent Monitoring Board (IMB)
16. An IMB is appointed to each prison by the Secretary of State for Justice. Its
members are wholly independent of the Prison Service and the prison’s
management team. Each IMB is required to produce an annual report to the
Secretary of State about the prison, highlighting good practice and any areas
of concern.
17. Lincoln’s latest IMB report covers the period 1 February 2008 to 31 January
2009. The Board noted that “drugs and mobile phones continue to enter the
prison but the proactive regime has resulted in a significant number of finds”.
When referring to safer custody, the Board noted that there had been two
deaths during the reporting year and 195 reported incidents of self-harm.
They said that the Listener’s scheme was well used and there was a well
regulated violence reduction policy.
18. Since this office assumed responsibility for investigating all deaths in prisons
in 2004, 14 deaths at Lincoln have been investigated. Ten of these were
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apparently self inflicted. The report of one of these has yet to be published.
In respect of the other nine, none of the recommendations made are relevant
here.
Assessment, Care in Custody and Teamwork (ACCT)
19. ACCT is the process used to monitor and support prisoners assessed as at
risk of committing suicide or self-harm. Once placed on an ACCT plan, the
prisoner is observed during the day and night at intervals determined by their
perceived level of risk. Amongst other things, the ACCT guidance states that
prisoners should be cared for in a safe environment. It is for the case review
team to decide the most appropriate place to locate an individual prisoner
within a prison.
20. Prison Service policy is that whenever, a prisoner harms himself, an ACCT
plan must be initiated and the following procedures carried out:
• A Concern and Keep Safe form must be completed as soon as
possible after the initial risk has been identified.
• An Immediate Action Plan must be compiled within 24 hours of the risk
being identified.
• An assessment interview must also be completed within the same time
scale.
• A first case review must also be held within 24 hours. At this review a
Care and Management Plan (or Care Map) must be agreed with the at-
risk prisoner. Subsequent reviews must also be planned if it decided
that the ACCT plan must remain open. When it is considered
appropriate to close the ACCT plan, a post closure review must be held
within seven days of closure. Case review panels must comprise a
multi-disciplinary panel and must make judgements as to the level of
risk the prisoner presents and how often he/she needs to be observed
and engaged in conversation.
Association
21. Association is the period of time when prisoners are unlocked from their cells
and are able to associate with each other.
Canteen
22. Prisoners can buy goods such as tobacco, sweets, soap, toothpaste etc via a
process known as ‘canteen’. However, canteen is also the term used for
those goods once they have been purchased and are in a prisoner’s
possession.
Counselling, Assessment Referral Advice and Throughcare service (CARATs)
23. The CARATs team provides assistance to offenders with a range of drug or
alcohol related problems. They assess prisoners and provide counselling and
support, as well as referrals on release, and implement care plans.
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Cell sharing risk assessment (CSRA)
24. The CRSA is used to assess the risk a prisoner poses to a cellmate if they
are required to share a cell. All prisoners are subject to this assessment on
reception and includes taking into account the situational context of any
previous violence or mental health issues. It is a live document, which is
reviewed at any point and follows the prisoner on transfers to another
establishment.
Cut down tools
25. Cut down tools are used to cut ligatures. All staff in closed and semi-open
prisons who have contact with prisoners are issued with and must carry their
own tool.
Emergency codes
26. Lincoln operates a code system to help staff alert their colleagues to an
emergency through the radio network. Code 1 indicates a life-threatening
emergency (for example, a heart attack or hanging). Code 2 indicates a non
life-threatening act of self-harm.
27. When a code 1 is used, it is broadcast to healthcare as “hotel 1” and
healthcare staff must attend with their orange emergency bag. Amongst other
equipment, it contains observation equipment, a blood pressure machine,
pulse meter, minor dressings, oxygen masks, ambu-bag (to assist with
breathing) and some emergency medication such as adrenaline. Other
equipment that should be carried to a code one includes an oxygen cylinder
and a defibrillator (this monitors the heart’s activity).
Incentives and Earned Privileges scheme (IEP)
28. The IEP scheme was introduced to encourage and reward good behaviour in
prisons. There are three levels: basic, standard and enhanced. Incentives
include access to in-cell television, more private cash to spend, being able to
wear their own clothes, more time out of cell and access to extra and
enhanced visits. Each prison sets its own criteria to obtain each level.
Personal officer scheme
29. The personal officer Scheme was introduced to give prisoners a more
consistent approach in a prison. The scheme is nationally operated but each
prison has its own way of delivering it. Prisoners are given a named officer
that they can approach for general advice or to resolve complaints. The
officer also completes reports on prisoners for which they are responsible and
ensures entries are made in their wing history files.
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Police investigations into deaths in custody
30. The police are notified by the prison as soon as any death has been
discovered. In the first instance, the police treat the area where the person is
found as a potential crime scene and as part of their investigation, note the
names of everyone involved and those who have been in contact with the
body. Additionally, they note the identity of all those entering and leaving the
cordoned area. It is only when the police are satisfied that the death is not
suspicious that the Ombudsman’s investigators are allowed to begin their own
investigations.
Licence and recall
31. Prisoners are generally released into the community on licence partway
through their sentence. They are given licence conditions which generally
state that the released prisoner should attend at the probation office to see
their probation officer on a pre-arranged basis. Conditions also relate to the
prisoner living at a particular address and being of good behaviour. Licence
conditions are linked to the risks that the prisoner poses and are specific to
that particular individual and their offence. If a prisoner on licence fails to
meet the conditions they will be recalled to prison to serve the remaining part
of their sentence.
Listeners
32. Listeners support vulnerable prisoners, particularly those at risk of suicide
and/or self-harm. They are trained, selected and supported by Samaritans to
offer confidential emotional support, 24 hours a day, to fellow prisoners in
distress.
Rule 45/vulnerable prisoners’ unit (VPU)
33. Prison Rule 45 relates to the segregation of prisoners for the good order of
the prison or for their own protection. They can be moved to the vulnerable
prisoners’ unit or the segregation block.
Security Information Reports (SIRs)
34. A security information report may be submitted by any person who believes
there to be a threat to national security or the security of a prison
establishment. It can also contain information needed to keep good order and
control within a prison and to prevent and detect crime.
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KEY FINDINGS
35. The man was familiar with prison life, having served a number of short terms
in custody. He was sentenced to three years and six months imprisonment
on 16 January 2006 and released on licence on 29 June 2007. The man was
recalled to Lincoln prison a few weeks later on 1 August 2007, for failing to
attend a Probation appointment on 24 July 2007 and for not residing at his
approved address for three weeks, having been evicted a few days after his
release from prison.
36. On reception at Lincoln, the man said he was detoxifying from heroin with
support from his community doctor. He also said that he had problems with
his use of alcohol. He was therefore referred to the CARATs team.
37. In his first healthscreen assessment, the man said he had no concerns about
harming himself and no mental health problems. However, the medical
record states that he presented “in low mood” and that he discussed and
agreed to resume taking mirtazapine, an anti depressant. He was also put
on a managed withdrawal programme dosage of diazepam (to treat anxiety)
and Subutex (to prevent withdrawal symptoms). This was given in a reducing
dose over a two week period ending on 15 August 2007. The man was also
prescribed ibuprofen and paracetamol (painkillers), zopiclone, (a short term
sleeping tablet) and chloradiazepoxide, (an anxiety relieving drug, used when
someone is withdrawing from drugs or alcohol). It is important to note that
wing staff do not have access to clinical notes because these are confidential
to healthcare and PCT.
38. The man was put on C wing at the prison and a note was made that he should
not come into contact with another prisoner, Mr B, who was on B wing. His
induction records inform that Mr B was then in a relationship with the man’s
wife.
39. On 7 October 2007, the man approached staff with serious concerns for his
safety because of the debts he had incurred on C wing. He said that he
“owed 10 packs of tobacco to various people”. He therefore felt under threat
and pressure to pay this back but could not do so at the time. He felt the debt
would follow him to another prison or any other wing other than the Vulnerable
Prisoners’ (VP) wing. The man was asked to make a statement naming who
was putting pressure on him, but he refused to do this, so he was advised that
he could not go to the VP wing. In response the man used a razor to make
superficial cuts to his wrists. Staff therefore placed him on the ACCT suicide
and self-harm prevention procedures.
40. As part of the ACCT assessment, the man reiterated his concern for his safety
and said that he was not attempting to kill himself but to show staff how
desperate he was to move to another wing. No triggers for the self-harm were
recorded on the appropriate page of the ACCT documentation, but the
concern and keep safe form said that the man had harmed himself because
he was heavily in debt and unable to repay what he owed. He felt very
threatened and vulnerable and asked to be made subject to rule 45 and go to
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the VPU or the segregation block for his own protection. Officer A completed
the assessment interview and noted that, as The man had now been granted
VP status, he no longer had any further problems. He had cut his wrists as a
cry for help rather than as an attempt to kill himself.
41. The man then moved to the VPU (E wing). Senior Officer A and Officer B
carried out a review of the ACCT on 11 October 2007. The man said that
most of his problems had disappeared now that he had moved wings. He
believed there was no reason for staff to continue monitoring him under the
suicide and self-harm procedures, so the ACCT plan was closed. A post-
closure review date was set for 18 October 2007, but there is no evidence that
it took place. The people present at the review stages of the ACCT were wing
staff. There was no health or mental health input into the assessments or
plans.
Allegations of bullying
42. On 14 January 2008, a prisoner made an allegation that the man had bullied
him. As this could not be substantiated, no further action was taken. The
man subsequently settled into E wing and records in the wing history book are
positive, showing that he was eventually raised to enhanced IEP status on 14
February 2008.
43. A Security Information Report (SIR) completed on 13 March 2008 gave
corroborated information that the man had verbally abused another prisoner in
the workshop. The man was put on stage 1 of the violence and anti-social
behaviour procedure (VAAB). The procedure requires wing staff to observe
the prisoner on the VAAB and make notes about his behaviour.
44. The next day, wing staff saw the man with a large bag of canteen that they did
not believe was his. A further SIR was completed reporting that The man
tried to persuade the cleaners to obtain drugs from the main wings and he
paid another weaker prisoner to act in a bizarre way. Staff put him on stage 2
of the VAAB and his status was reduced to the basic regime. Observations of
the man’s behaviour were continued.
45. A number of further SIRs stated that the man was dealing Subutex on the
wing. This information came from other prisoners. Staff responded with a
range of actions, from observation of the man and mandatory drug tests, to
thorough cell searches. He was also referred to Ms E, a psychologist. In her
report dated 27 March 2008, she recommends that his drug misuse should be
addressed. She noted that he had applied to attend a drug programme but at
that time it had been deferred because of the man’s lack of motivation to
engage.
46. Ms E also recommended that the man should “address his cognitive deficits”
by attending the Enhanced Thinking Skills Programme (ETS). (The ETS
programme teaches offenders to become aware of their thought processes
and learn to change them so that their actions and behaviour changes, with a
view to reducing their offending and lowering their risk.) Ms E said that the
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man had been considered for a place on ETS at HMP Stocken in 2006, but
was not offered a place because “he did not meet the intellectual functioning
criteria”. Attendance on ETS programme has a particular criterion, which
requires the attendee to have a certain level of thinking skills. This is
assessed by psychometric tests. However, the man said he would discuss
working on his thinking skills on a one to one basis but would not comply with
targets if he had to do the whole of the remainder of his sentence. There is
no evidence of the man taking part in either of the above programmes prior to
his death.
47. On 28 April 2008, a prisoner reported that the man was receiving Subutex at
visits and bullying prisoners in the medication/treatment queue. A further
report alleged that the man had a mobile telephone.
48. Staff conducted a search on 13 May 2008 and found a number of items in the
man’s cell. These were:
• Excess tobacco
• 14 batteries
• Two pieces of foil
• Half a Subutex tablet wrapped in a plastic bag (found in the man’s track
suit bottoms)
• Hand drawn map of the laundry area.
49. In line with prison policy, staff confiscated the property and reported the man
for a disciplinary offence. A prisoner made a further allegation that the man
paid a prisoner an amount of tobacco to assault another prisoner. Staff
subsequently dismissed the man from his job in the laundry. Wing history
records show that he was disinterested in this.
50. On 16 May 2008, a number of prisoners completed statements saying that the
man was still “bullying and lending out”. (Lending out is a term used when
prisoners lend out property or money for repayment or profit.) SIRs on 17
May alleged that he threatened another prisoner saying he would not be able
to “ … eat his tea tonight. Even if he was banged up, it would be taken care
of”. (The term banged up means when a prisoner is behind his locked cell
door.) This prisoner was recorded as being “frightened to come out of his
cell”. Another prisoner said that the man had sold Subutex for £25 and was
now pressurising the prisoner for the money, to the extent of threatening him
by putting an unknown price on his head.
51. It is not clear from the records when the man came off stage 2 of the VAAB
procedure but he submitted an appeal to Governor A on 22 May 2008, saying
that he had been put back on stage 2 after “just being taken off basic on 21
April 2008”. The man’s comments were:
“ … because I have been on stage 1 and 2 up until the 21 April, I was
placed back on stage 1 on 24 April, for apparently bullying at laundry. I
was 2 days from being back to usual, then on Saturday I was placed on
stage 2.”
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52. The man then complained about a number of officers and asked for evidence
for why he had been put back on stage 2. He said in the appeal form that he
had stopped bullying after his last incident. Governor A replied that he would
investigate the matter further and write to the man again. The investigator
asked for the subsequent response to this matter and was told that at the time
of the man’s death the complaint was still in the administrative processes.
Assessment, Care in Custody and Teamwork 28 May
53. An ACCT plan was opened on 28 May 2008 at 8.30am by Senior Officer B,
when staff advised the man that he would be transferred to HMP Nottingham
that day. The man was expecting a visit from his sons the following day and
was very angry and upset that he would miss seeing them. He told the officer
that if he was moved before his visit he would “cut up”. According to Senior
Officer B, the man then made superficial cuts to his wrists with a razor blade.
He refused to be assessed or treated by healthcare staff. In view of his
actions, he was placed on the ACCT monitoring procedures with hourly
observations and conversations. At 4.05pm, Senior Officer C and Officer C
reviewed the ACCT. The man said he had been waiting for ten months for a
visit from his ex-wife and sons. He was also upset that he was on the VAAB
stage 2 and felt he had been “set up”. He said that he only cut himself so that
he would be heard and did not tell staff who he thought had implicated him.
54. Senior Officer C wrote in the review that this was an isolated incident because
the man wanted to make sure he would have his visit the day afterwards. She
then closed the ACCT procedures at 4.20pm. The man did not transfer. On 4
June, Senior Officer B completed the ACCT post-closure review. The man
said he had no problems, after having his visit.
55. Staff recorded in the wing history sheets that, from 9 June 2008, until the
man’s death, he refused to come out of his cell and declined exercise. On 11
June 2008, Officer D told Governor B that the man wanted to see her about
his request to go to the segregation unit. Governor B made a number of
enquiries with other managers about his request. Governor C told her that his
allegations of bullying were being investigated and they did not think that the
man’s move to the segregation unit was justified at this stage. She asked
Officer D to tell him that she would speak to the other governors the following
day and a decision would be made about his location. She then emailed
Governor D and Officer D, asking them to confirm whether they were dealing
with the bullying investigation and the progress on it. She copied it to Officer
E as the violence reduction manager. The investigator has not had sight of
this email because it has been deleted from the system. Governor B then
discussed the issue at the staff briefing on 12 June 2008 and asked Governor
D to speak to the man about his request.
Evening and early morning of 12/13 June
56. Senior Officer B said that throughout 12 June 2008, the man’s behaviour was
“becoming increasingly bizarre”. He put furniture behind his cell door and
16
barricaded himself in. He was screaming and shouting, pleading for Officer E
not to hit him. Officers were initially concerned about his mental health, but
said he became lucid a few minutes after each episode. This went on until
lunchtime, when Officer F opened the ACCT monitoring procedure.
57. Officer F made the first note on the ongoing record in the ACCT document at
1.15pm. He said that he was concerned because the man told him that
officers are talking about him all the time and that he has had enough and will
“cut up if he hears anything else”. Officer F also mentioned that the man had
shown him a blade that he was going to use.
58. The next page of the ACCT document is the immediate action plan,
completed by Senior Officer B and Officer G at 2.30pm. It does not say if they
removed the blade and it is not clear from any statements made
subsequently. However, there is no further mention of the blade being in the
man’s possession. The actions mentioned in the plan were as follows:
• “Re his location – The man is happy to be alone at present. He is high
cell share risk assessment (CSRA)
• Re frequency of support – Hourly observations and conversations
when awake.
• Re phone access – As and when required
• Re Listener access – High risk – unsuitable for Listeners – access to
Samaritans phone.
• Re other immediate interventions – the man states he was purely trying
to instigate a move to D wing by threatening self-harm – states he has
no intentions.”
59. At some time in the afternoon before 4.00pm, Officer E and Senior Officer B
talked to the man in his cell. Officer E said that the man was acting “very
paranoid, saying he had heard staff radios saying things like, he’s grassing
you all up, it’s the man, he’s grassing you all up”. When the man calmed
down he explained that he had taken £100 from a prisoner, Mr C, to buy
drugs for him. He also said he owed prisoner Mr D £80 for Subutex and
another prisoner £60 for tobacco. He said that he had planned to get these
drugs through visits from his ex- wife but she did not bring them, leaving the
man in debt to the two prisoners. He said that they had threatened to “slash”
him a week ago and they were making threats through his cell door. He also
said that prisoners from other wings were making threats to him for “grassing
up his missus”. The officers checked cash disbursements and found that on 7
May 2008, Mr C had sent out £160 to the man’s ex-wife.
60. Officer E wrote what the man had told him in annex B of the VAAB records, so
that anti-bullying proceedings could be started against the two prisoners. The
man said that he felt under threat on E wing and the other wings and wanted
to go to the segregation unit on D wing. Officer E told the man that he was
unlikely to be moved because he was subject to ACCT procedures. The man
then repeatedly said “well I’m not suicidal, I’m not going to hurt myself, it’s just
a ploy to try and get off the wing”. He refused to sign his statement about the
two prisoners because he would not be moved off the wing.
17
61. Officer E then made enquiries about the man’s request to be moved, with
Governor E, who said “well that’s ok, move him”. However, when he was told
that the man was subject to ACCT monitoring he said that the man could not
be moved because “that was different”. The investigator asked why the man
could not go to the segregation block if he was subject to ACCT procedures
and was told that there was not enough support there and the risks to the
man’s health were potentially higher in that environment because of the
isolation.
62. Later that afternoon, Officer E saw Governor D (Head of Residence) and told
him about the man. Governor D said “well this can’t go on like this because
the poor lad is not going on exercise, he’s not coming out of his cell; he’s not
getting anything at all”. He said that he would speak with Governor E.
63. At 4.00pm, Officer C completed the man’s ACCT assessment interview. This
should be completed within 24 hours of the concern being raised. The man
said he had debt problems on the wing and reiterated that he took money
from other prisoners with the intention of supplying them with drugs, which he
had arranged to be brought in via visits. The person with whom he made
these arrangements had now spent the money and the debt now lay with him
(the man). He wanted to go to D wing and at dinner time, said he would harm
himself to get off the wing. He explained that he only said it to get moved and
he “didn’t mean it”.
64. The man told the officer that prisoners were calling him names and said that
he felt “hounded by the other prisoners and felt stressed out”. The officer
noted that the man was using the ACCT to manipulate the system and that he
had no real thoughts of self-harm or suicide. The officer then commented on
the section covering previous self-harm and suicide attempts that the man
“has a history of self-harm, cut wrist this was to get off C wing last year, cut
wrist again to get out of going on tx (transfer) to Nottingham last month”. Of
his current mental state, he said “feel ok, just want off E wing” and he had no
current suicidal thoughts or intentions. In the section titled “Any other areas of
discussion”, it is recorded that the man “feels he has done the right thing and
what has been asked of him by making statements and naming names. Feels
stressed he is still here on the wing.”
65. The action following the above assessment was completed by Senior Officer
B, Officer C and the man. The man was advised that he would not be moving
to D wing and due to his IEP basic status, he was unable to have tobacco.
Staff agreed to keep the ACCT plan open but to reduce to minimum
observations of three per day, to support the man. At this time, they assessed
him as low risk of further risk of self harm. Staff then completed a care map
with four objectives. For the man to:
• Be in and out of his cell to use his time constructively.
• To share a cell.
• To be located in a safer cell.
• To have family contact.
18
66. However, it was noted in the care map that “the man is refusing to engage in
out of cell activities at present” and “the man is currently a high risk cell
sharing assessment and is refusing to share”. Approval for him to be located
in a safer cell was noted. (A safer cell is defined as one in which the
opportunity for a prisoner to hang himself is minimised. The man was not in a
safer cell, when he died.) He was said to be in regular contact with his
children (although he had previously said he had waited ten months for a visit
from them). The next review was scheduled to take place on 16 June 2008.
67. In the ongoing record, Officer G noted at 1.50pm that the man is “losing it –
becoming paranoid”. After the assessment at 4.00pm, there are three entries
at 6.30pm, 7.55pm, 11pm on 12 June 2008 and then at 8.05am on 13 June
2008, which is when the man was found hanging.
68. On the front sheet of the ACCT document neither the man’s date of birth, nor
the date that the ACCT was opened were recorded. The next page of the
document did not include triggers or warning signs and was not signed by the
man. The record of handover and briefing of ACCT documents page started
at 1.30pm and the name of the officer is illegible but Officer H (the man’s
personal officer) also put his name on it.
69. At interview, Senior Officer B said that he believed the man when he said that
he had only cut himself in order move cells and that he would not harm
himself which is why he changed the observations to the minimum. He also
said that if he had the power to move the man he would have done so
because he knew him and saw his “bizarre behaviour” as a plea for help. He
believed the man’s situation was “dire”. Senior Officer B added that he saw
him in the evening when another member of staff reported to him that he had
barricaded everything up behind his cell door. The SO advised that staff take
no action but should keep an eye on the man. After ten or 15 minutes the
man had taken down the barricade. Senior Officer B said he spoke to the
man but could not recall what they talked about.
70. At 8.30pm, the night Officer Support Grade (OSG) T went to the wing for a
handover about prisoners on ACCT plans. He said there were 13 prisoners
subject to ACCT monitoring on the wing. The OSG told the investigator that
he was not ACCT trained at this time. He said he was told how to do ACCT
monitoring by another OSG but he did not know if the other OSG had been
trained. The man was on minimum observations, one in the morning, another
in the afternoon and the evening but no night checks were required.
71. OSG T checked the man at 11.00pm and wrote in the ongoing record, “The
man on his back, appears asleep”. He said he answered the man’s cell bell
later that night but he was not sure what time. (Each cell has a bell which
prisoners can press if they need urgent help.) The man asked for a cigarette
but OSG T said he did not smoke and could not give him a cigarette.
72. OSG T said that he carried out the morning roll check (count of prisoners) at
approximately 5.40am. He saw the man sitting on his bed. He asked him if
19
he was okay but he did not answer. OSG T said that was not unusual and he
had no concerns. The man’s cell furniture was in the normal position at this
time. OSG T said he did not hear any unusual shouting over the night, nor did
he hear any furniture being moved. He left the wing at about 7.30am.
73. Mr E, a prisoner, told my investigator that he was in the cell next door to the
man on the night of 12/13 June. About 8.00pm on 12 June 2008, he heard
the man shouting out of his window, to another prisoner, Mr D. He heard the
man shout, “I’ll show you bastards tomorrow”. He thought that the man meant
he was going to hit Mr D or someone else who he was shouting to. Mr E
heard OSG T at the man’s cell door around 6.00am and he heard the man
asking him for a light. The OSG refused and the man shouted, “I will punch
your lights out”. He heard the man’s cell chair bang between about 6.00am to
6.30am and thought that the man, might have kicked it in temper. He also
told the investigator that no morning roll checks were done, until the man was
found at about 8.00am. However, a copy of the morning roll check was given
to my investigator.
74. Mr F, a prisoner, told the investigator that in the evening of 12 June 2008, the
man told him that a fellow prisoner, Mr C, had “grassed him up for dealing” so
the man had “grassed up “Mr C” ”. (The term grassed up is when one person
informs on another.) Mr F said he had seen Mr C at the man’s cell door on
the night of 12 June 2008 and he heard Mr C say “If you grass me and I get
put on bullying I’ll show you what bullying is”. An officer then moved Mr C
away from the man’s cell. Mr F said that the man had stayed in his cell for
three or four days because he was being bullied by Mr C. He also said that
he thought the man had mental health problems as he was erratic but did not
have any concern that he would have harmed himself. He said the man
would buy and sell anything and always had, “sweets, biscuits, tobacco etc
but recently he had none”.
13 June
75. Officer J came on duty at 7.45am on 13 June 2008 and was given a briefing.
She told the investigator that she was the ACCT worker for the wing. (The
ACCT worker is the person who checks all prisoners subject to ACCT
monitoring, as per the instructions on the front of the ACCT document.)
76. Officer J explained that the man was having morning, afternoon and evening
observations which meant the ACCT worker should have a meaningful
conversation with him during these times and then complete the ongoing
record. The officer said that she felt under pressure because there were so
many prisoners subject to ACCT procedures. She had previously brought this
to the attention of governors previously and had written it in the observations
book. She said “there is no way I can keep prisoners safe, as is my job as
keyworker, when there are 13 of them”. She said there were 14 prisoners on
open ACCTs on 13 June 2008, with one prisoner having constant supervision.
Most of them were to be checked every half hour or hour.
20
77. Approximately 8.04am, Officer J went to the man’s cell, E13 and looked inside
through the door flap. She saw what she thought was the man standing,
looking at the picture board on the wall. As she went to walk away, she felt
that something was not quite right and so she checked again. She tried to
open the door and Officer K, who had seen the distress in her face, went to
help her. They were unable to open the door and Officer L also went to help.
78. Officer J called a code 1 emergency over the radio but the controller didn’t
hear clearly at first so she immediately put the call out again. Senior Officer B
and Principal Officer A went to the man’s cell door. The door had been
barricaded by cell furniture and the man was hanging from a ligature, which
was tied to the cell window bars. For a few moments the staff tried to open
the door but realised that they could not open it. An officer went to get a
special Allen Key that enabled them to open the door outwards. This key was
kept in a locked cabinet in the office on the threes landing. Other officers and
healthcare staff responded to the call and saw officers trying to kick the door
inwards. As the cell was on the ground floor, Senior Officer B then ran
outside the wing and used his cut down tool to cut the man down from the
window bars.
79. Whilst Senior Officer B did that, the cell door was opened with the Allen Key.
Officer L and Senior Officer D went in, climbed over the man’s chair and bunk
bed, onto the sink. They jumped over to where the man was lying, the
ligature having been cut by Senior Officer B. Senior Officer D told the
investigator that the barricade had been made by the man moving his cell
chair against the door, then pushing the bunk bed and finally moved his
cabinet against them.
80. There was not enough room in the cell for the healthcare staff to treat the
man. Therefore, while they were waiting to get into the cell, they decided that
it would be best to move him out of the cell, onto the landing to treat him.
Senior Officer D and Officer L lifted the man onto the top bunk, whilst Officer
M moved the other furniture out of the way. They then lifted him out of the cell
and laid him on the landing and the nurses took over. My investigator asked
Senior Officer D when an ambulance was called. He said that he was not
sure whether if a code 1 was called; the controller would call an ambulance to
put it on standby. Officer M said he asked control to call for an ambulance.
81. Nurse A responded to the code 1 call. She told the investigator that, whilst
officers were trying to get the man out of the cell, she and the other healthcare
staff discussed how they would manage the situation. They agreed that to
treat the man in the best way it would be better to move him out, because
there was very limited room in the cell. They was decided that Nurse B would
take the man’s airway, Officer E would carry out chest compressions and she
and another nurse would get the equipment ready. All four had been fully
trained to deliver cardio pulmonary resuscitation (CPR). In the meantime,
Nurse A managed to get into the cell and make some observations of the
man. She described him as “floppy and not moving. His pupils were fixed
and dilated, there were no breaths”. She checked for a pulse in his thigh and
there was none.
21
82. As soon as the man was brought onto the landing, Nurse C started chest
compressions at a ratio of 30 compressions to two breaths, as per clinical
guidelines. Nurse A connected the defibrillator and Nurse B put in an airway
and attached oxygen and an ambu bag. (A defibrillator measures electrical
activity in the body and advises on the action to be taken. An ambu bag
provides ventilation to a person who is not breathing.) Nurse B told the
investigator that there were no signs of life at this time. The defibrillator
advised not to shock. They carried on with compressions and oxygen until
8.20am, when the ambulance and paramedics arrived. The ambulance staff
took over CPR and gave the man atropine, (Atropine is a drug used to
increase the heart rate and reduce secretions.) to which there was no
response. The man was pronounced dead at 8.41am.
83. Whilst this was happening, prisoners were taken back into their cells and a
screen was put around the man. Staff also conducted a review of prisoners
on the wing at risk of harming themselves.
84. Lincolnshire Police went to the prison and started an investigation. They took
possession of the ligature and a letter that the man had written, dated 11 June
2008. My investigator received a copy of the letter from the police in May
2010. It was addressed to xxxx/to whom it may concern. In the letter, the
man said that he had got into trouble on the wing and that he had given the
names of the people to whom he owed money to staff. He also wrote that he
had complained about staff and he believed they were going to let those to
whom he owed money into his cell in the morning, “to drag me out to the
shower rooms and … I’m going home in a body bag”. He went on to say that
suicide would be less painful than what some prisoners had in mind for him.
85. The duty care team attended and spoke to some of the staff who were
involved with the man. Governor F then had some meetings with the staff
who had attended to the man. It is not clear from the interviews how many
meetings took place but it seems that there was one called a hot debrief. (A
hot debrief is a meeting for staff to discuss emotive issues and any lessons
learned following serious events such as deaths in custody, hostage
situations or escape attempts.) Staff did not seem to be clear as to the
purpose of the meetings. Several of them said during interview that they did
not feel that the hot debrief was useful. They said it seemed to be an attack
on them rather than a supportive environment. My investigator was also told
that in one of the meetings, Governor F had spoken about the man’s brother
having committed suicide previously and said that the man’s girlfriend was
meant to bring drugs into the prison for him. Staff did not feel that this was
appropriate.
86. At the time of his death, the man had nominated a friend as his next of kin.
After making extensive enquiries within the prison and Probation Service, the
prison family liaison officer telephoned the man’s ex wife and arranged for her
to go to the prison. She then made arrangements for the man’s funeral and
agreed that the prison would pay the costs. When a death occurs in a prison
22
staff are required to contact the prisoner’s listed next of kin, which is not
always necessarily the legal next of kin.
87. When she went to the prison, the man’s ex wife explained that the man had a
sister and asked the prison liaison officer to inform her of his death. I
understand the man’s sister was not told of his death until later in the day and
that this was by telephone. My investigator asked the Governor about this
and was told that the prison did not have details or the address of his sister
and relied on information obtained from the man’s ex-wife.
Additional information given by prisoners and staff after the man’s death
88. Over a few days after the man’s death, a number of prisoners came forward
to give information. One prisoner told my investigator that the man was
dealing in Subutex and mobile telephones on the wing. He initially said that
this was with the help of a prison officer, who was giving the man “a hard
time” on the wing. However, when he was sent the interview notes for his
signature, he denied that he had ever said that the officer was involved in the
bullying. He made allegations about other officers on the wing and said that
he had put in a complaint about one of them. However, when my investigator
asked the prison for any information about this, she was told that there was no
record of any complaints being made about that officer.
89. Mr G, another prisoner, wrote to Her Majesty’s Inspectorate of Prisons
(HMIP). In his opinion, the man’s death was due to the negligence of prison
officers. My investigator made enquiries and was told that HMIP had replied
to Mr G telling him that the Ombudsman’s office would deal with the issues
when they investigated the man’s death. He did not come forward to be
interviewed at the time and, when my investigator made enquiries in 2010, he
had been released.
90. My investigator made further enquiries about the allegations of a prison officer
being involved in the man’s death. She was told that about two weeks before
the man’s death, Senior Officer B had given information to the prison security
department about the possibility that an officer was taking drugs and mobile
phones into the prison. An investigation was started and in mid July 2008, an
officer was suspended pending a disciplinary investigation. Lincolnshire
Police were notified and a criminal investigation began. This was later
considered when the police investigated the man’s death and is discussed
later in this report.
91. My investigator conducted a further interview with Senior Officer B on 11
March 2010, when he gave an account of what he thought might have
happened between the man and the officer who was subject to disciplinary
and criminal investigations. As a result of the information given in the
interview, Lincolnshire Police made further enquiries with Lincoln prison staff
and they re-interviewed Senior Officer B and two other staff members to
clarify the issues raised, particularly with regard to the allegations that a
prison officer had been involved.
23
Police statements and potential involvement of corrupt prison officer
92. Senior Officer B made a further statement to police on 21 May 2010. He told
them that at no point had the man told him that he was being put under
pressure by the officer but had said that he was being bullied by a prisoner.
Senior Officer B said that he formed the impression that the man wanted to
tell him more but “could not do so”. He said it was his personal opinion that
the officer may have been behind the prisoners’ bullying of the man. Senior
Officer B reported his concern on SIRs which were passed to the security
governor. The allegations made against the officer were investigated by a
Governor from another prison between February and May 2009. A number of
disciplinary charges were laid relating to trafficking of contraband, entering
into an inappropriate relationship with a prisoner and assisting prisoners to
damage prison property.
93. The charges were heard at a Prison Service disciplinary hearing on 16
November 2009. All the charges were proved and the officer was
subsequently dismissed. The matter was referred to the Lincolnshire Police
for them to consider criminal charges. On 10 May 2010, the Crown
Prosecution Service decided that there was not enough evidence to progress
with any criminal charges.
94. No evidence arose from either the internal Prison Service investigation or
from the police investigation to show that there was a connection between the
prison officer and the man’s death.
24
ISSUES
Clinical care
95. Dr A, a consultant in public health medicine at Lincolnshire Primary Care
Trust, conducted a review of the man’s clinical care and treatment at Lincoln.
Reception assessments revealed that the man admitted to daily use of drugs
and alcohol. He had also harmed himself in the past, but at that time had no
thoughts of self-harm or suicide. He had no mental health support in the
community, but was referred for a mental health assessment at the prison.
Subsequent appointments at the mental health clinic were either cancelled
due to staffing levels or the man failed to attend. In respect of the
management of the man’s episodes of self-harm, Dr A considered that it
“would seem unlikely therefore that prison staff could have foreseen that the
man would hang himself.”
96. Dr A concluded that it was unlikely that resuscitation could have been
successful in this case. He said prolonged efforts were made to revive the
man. All the equipment was in working order and the nurses’ description of
their attempt to resuscitate the man was in line with guidance from the UK
Resuscitation Council.
97. The man had a repeated prescription of mirtazapine. However, this was not
noted in his continuous clinical record. Dr A would have expected to see an
indication of why this drug was started and a regular assessment of his
progress whilst taking the drug. Dr A makes a recommendation concerning
this, which I endorse.
The Governor and Primary Care Trust should advise healthcare staff
that an entry should always be made in the continuous clinical record
when a patient is prescribed an antidepressant drug. Patients on
antidepressant drugs should be assessed at regular intervals, not less
than monthly and entries should be made in their clinical record
following each assessment.
Assessment, Care in Custody and Teamwork monitoring
98. The man was made subject to ACCT procedures on 7 October 2007, after
cutting his wrist. He said he felt threatened by other prisoners on the wing
because of debts he had created. The ACCT documentation was not
complete. No triggers were recorded and there is no evidence of a post-
closure review taking place on 18 October 2007. Also, there was no mental
health input into the assessment. The man was briefly placed on ACCT
monitoring on 28 May 2008.
99. On 12 June 2008, the man was again placed on an ACCT plan. Again, many
key areas of the document were incomplete and it had not been signed by the
man. The CAREMAP contained four objectives. I do not believe that the first
two were achievable and although the third (for the man to be located in a
safer cell) was approved and accepted, it regrettably did not take place.
25
There are no safer cells in the vulnerable prisoner unit where the man died
and it is therefore unclear where he would have been placed.
The Governor should reinforce to staff that all ACCT documentation
should be fully completed and that objectives set in the CAREMAP
should be achievable and realistic.
100. The man was subject to being supported by the ACCT procedures when he
died. He had not been moved to a safer cell and he was on minimum
observations. Despite the fact that the man had moved his furniture and
barricaded himself into his cell during the day of 12 June 2008, he was left in
that cell overnight with no additional overnight monitoring put in place,
allowing him to further barricade himself in when he took his life.
101. Staff said the man was “becoming increasingly bizarre”, during the day. He
had barricaded himself into his cell and was acting “very paranoid”. He was
also screaming and shouting allegations against staff. The man then harmed
himself. Although a number of staff said that the man was acting in a clearly
distressed way, no mental health assistance was requested and there was no
mental health input into the ACCT.
The Governor should ensure that additional ACCT reviews are carried
out following significant events, such as a prisoner’s behaviour
deteriorating and that those reviews should be conducted as a multi
disciplinary function, embracing the expertise of specialist staff such as
the healthcare team, chaplaincy and others.
102. When the night OSG had contact with the man on the night of 12/13 June
2008, he did not record this on the ongoing record on the ACCT document.
However, he said that he had never had ACCT training and had been told
how to carry out ACCT procedures by another OSG.
The Governor should ensure that all staff who have contact with
prisoners are given an appropriate level of ACCT training.
103. My investigator was told that there were 13 prisoners subject to ACCT
monitoring during the night of 12 June 2008 and 13 the next day, including a
prisoner on constant observation. Staff said that it was impossible to keep
prisoners safe when there were so many to monitor. Despite bringing this to
the attention of governors previously, nothing had changed.
The Governor should ensure that sufficient staff are provided to monitor
prisoners subject to suicide and self-harm procedures and adjust the
staffing levels to take account of the number of active ACCT plans.
104. Officers told my investigators that there was a marked difference and
deterioration in the man’s behaviour, approximately two weeks before he died.
Wing history sheets said that the man did not come out of his cell for some
days. There is no evidence of any intervention to find out why the man was
26
behaving differently until 12 June 2008 when the ACCT was opened after he
had harmed himself.
The Governor should ensure that staff seek appropriate medical
assessments if a prisoner displays signs of a marked deterioration in
their physical or mental condition.
Emergency calls
105. Some staff were unsure as to when to call an ambulance when a code 1 had
been called. Although a code 1 indicates a life threatening emergency, it is
unclear who is responsible for calling an ambulance.
The Governor should remind all staff of the procedures when serious
self-harm or suicide occurs and an ambulance is needed.
Basic regime under the IEP scheme
106. The man had been on the basic regime for two periods, from 14 March 2008
to 21 April 2008 and then again from 26 April 2008 to the time of his death.
Lincoln’s Suicide and Self-harm policy paragraph 9.22, says that:
“staff should be aware that placing an at risk prisoner on basic regime
(especially if it is for a prolonged time) will heighten risk because of the
reduced access to support from family and friends involved in the loss
of telephone calls and letters”.
On each occasion that the man was demoted to the basic regime, he was not
subject to ACCT monitoring and, in any case, it was indicated that he had
regular contact with family members. I therefore make no formal
recommendation on this matter, but the Governor might wish to remind staff of
the conflicts between the rigours of the basic regime and the increased risk to
prisoners at risk of self-harm. In particular I suggest that the ACCT reviews
should consider the impact of being on the basic regime and whether that
might impact on the prisoners well being.
107. During the early hours of 13 June 2008, the man asked the OSG on duty for a
cigarette or a light for a cigarette and was refused. Senior Officer B explained
that as the man was on basic regime he was not provided with tobacco and
could be seen going round the wing picking up “dog ends”. According to the
Integrated Drug Treatment Service (IDTS), there is evidence that nicotine
withdrawal can lead to prisoners taking their lives because of increased levels
of anxiety and agitation.
The Governor should ensure that prisoners at risk of suicide or self-
harm who require but do not have access to tobacco because they are
on the basic regime are assessed by appropriate staff and consideration
is given to providing nicotine replacement.
27
Violence and anti-social behaviour (VAAB) procedures
108. There is evidence that the man was bullying other prisoners to claim money
for goods he had provided. He admitted this and appropriately made subject
to anti-bullying procedures. The man denied a further instance of bullying and
appealed to Governor A. At the same time, he also complained about a
number of officers on the wing, saying that they were bullying him. Governor
A replied to the man’s complaint, saying he would investigate it further after
the result of his appeal. My investigator was told that, at the time of the man’s
death, he was still waiting for a response to his appeal and complaint.
109. In a statement to police on 21 May 2010, Governor F explained that the man
was using two different systems to appeal against the allegations of bullying
against him and make a complaint about the officers. She said that she did
not know if there had been a response before the man's death or what this
response might have been. She was clear that the correct procedure had
been followed by Senior Officer B and this was also checked by Governor A,
who confirmed that Senior Officer B had carried out the correct action.
The Governor should ensure that prisoner complaints are investigated
at the earliest opportunity as per Lincoln’s Request and Complaints
procedure and within the timescales set out in the policy. Prisoners
who make a complaint should be kept informed of its progress.
Moving the man to the segregation unit
110. Staff decided that the man should not be moved to the segregation unit
because he was subject to ACCT procedures. Governor F explained that a
prisoner subject to ACCT would only be moved to the segregation unit in
exceptional circumstances because it is not perceived to be a safe place for
people threatening self-harm because of the isolation within the unit. She
also said that statistics and policy indicates that there is a higher risk of death
in segregation units than any other area. There is only one safer cell in the
segregation unit, which has CCTV and special facilities. She said prisoners
would only go there as a last resort once all other avenues had been
explored. This would include prisoners being placed on confinement to their
own cells, which is what the man was offered instead of a move.
111. Three governors were involved in the decision not to move the man to the
segregation unit and from their comments, it would seem that they were not
wholly agreed upon that action. Officer E and Senior Officer B also felt that
the man should have been moved, based on their interaction with the man
and with Senior Officer B’s suggestion that an E wing officer was potentially
involved in the circumstances.
112. The man was offered cell confinement, which it seems he had taken upon
himself some days earlier, as a way to protect himself. This is at odds with
the first two objectives set in his CAREMAP in the ACCT plan. However, had
he moved to the segregation unit, he would have undergone a mental health
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assessment, which may have enlightened staff about his unusual behaviour
and possibly reduced the risk of him taking his own life.
113. The matter of whether the man should move to the segregation unit was
considered by several managers, as well as discipline staff and the rationale
for not doing so has been explained. There were conflicting views and I have
found insufficient evidence to second guess their judgment and decisions.
Debrief
114. According to staff, two meetings were held after the man died: one, which was
referred to as a hot debrief and another where Governor F called the staff to
her office. Staff said the governor told them that the man’s brother had taken
his life previously and that he had arranged for his ex-partner to bring in
drugs. Staff said they were extremely distressed and were pressed as to
whether they were at fault. They considered that some matters discussed
were inappropriate.
115. Some staff also considered that the hot debrief was not helpful. They said
that they were questioned about what had happened and did not feel
supported. Senior Officer E identified the man’s body to the Coroner’s officer
but was not invited to the hot debrief. OSG T was not invited to the hot
debrief and Senior Officer B was unable to attend because he was still
completing police statements.
116. Prison Service Order (PSO) 2700 paragraph 5.3 states that after a death in
custody or any incident of serious self-harm:
“Many staff experience “normal” short-term stress reactions (distress
and tearfulness, shock, feelings of guilt) and need to be reassured that
these reactions are normal. Debriefings are generally found useful
after a death in custody if they provide an opportunity to share
experiences, dispel inappropriate feelings of guilt and self-blame and
provide reassurance that stress is normal in these circumstances.
There must always be a hot debrief immediately after the incident and
provision for this should be made in local contingency plans. A senior
member of staff must act as debriefer and a duty care team member
must also attend. The purpose is not to analyse or re-live the incident.
Nor is it an opportunity to apportion blame or pre-judge investigation
findings. The hot debrief should focus on reassurance, information
sharing, normalisation and how staff can support each other. Particular
reassurance is needed when the prisoner died after unsuccessful
resuscitation attempts, when staff involved are more likely to feel a
sense of failure. Staff wanting but unable to attend the debriefing
should be followed up, as a group or individually.“
From the information given by staff members, the debrief did not fulfil the
above purpose. Staff were clearly left feeling uncomfortable and potentially at
fault. The Governor will wish to consider these views carefully.
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The Governor should ensure that after any incident of serious self-harm,
staff are invited to attend a hot debrief, carried out under the guidelines
of PSO 4710 and that relevant staff are able to attend. All staff involved
in an incident of serious self-harm should be offered the services of the
staff care team.
Supply of unprescribed drugs
117. I have come across the supply of unprescribed drugs in many investigations I
have conducted following the death of a prisoner. I am aware the Prison
Service works hard to combat this illegal trade within their establishments and
Lincoln is no different. I am pleased therefore that Lincoln staff and security
department and the police shared intelligence, which resulted in finding a
source of illegal drugs and mobile telephones and taking the necessary
actions.
Prison and Police investigation into the behaviour of a prison officer
118. The behaviour of the prison officer who was dismissed has been considered
closely in this case. Whilst Senior Officer B gave a statement saying it was
his opinion that the officer had been involved in bullying the man and that the
atmosphere on the wing changed dramatically after the officer left, I can only
find circumstantial evidence and opinion that this was the case. The
disciplinary and criminal aspects are outside the remit of this office.
Family concerns
119. The family raised a number of additional concerns which have not been yet
been addressed in my report.
• The prison chaplain attended the funeral although she had not been
invited by the family.
• The man was refused access to a Listener.
• The man’s sister was offered a visit to the cell where her brother took his
life but it was after the cell had been cleared. She felt that the prison staff
did not want to accommodate this.
• The prison family liaison officer was rude to the man’s sister.
121. The chaplain explained that she attended the funeral in a personal capacity
because she knew the man and had contact with him in the prison. She was
known to the minister who was conducting the service as she lives locally and
he introduced her to the congregation. He also asked her to read a passage
during the service. She said she was very sad that the family were not
satisfied with this. She did not wish to be disrespectful and was attending as
someone who knew the man, not as a representative of the prison. She told
my investigator that staff had a long discussion on how to avoid such issues in
the future. Whilst I recognise that the chaplain’s intentions were good, the
wishes of the bereaved family are paramount. I trust that the Governor and
chaplain will take steps to consult a family before attending or participating in
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a funeral service.
122. The ACCT plan opened on 12 June 2008 indicates that the man could not see
a Listener as he was too high risk. However, in place of this he was allowed
use of the Samaritans phone. The prison told the investigator that the man’s
cell sharing risk assessment had placed him at too high a risk to have a
Listener in his cell. It is important that the Listeners’ safety is protected and I
am satisfied that the decision about the man’s access to a Listener was
appropriate.
123. Regarding clearing the man’s cell, I regret that, given the lapse of time, it was
not possible to explore the circumstances, but I am satisfied that the prison
acted reasonably in offering the man’s sister the opportunity to visit.
124. Finally, the man’s sister considers that the prison’s family liaison officer was
rude to her. I understand that the family liaison officer explained to the man’s
sister that, as she was not his nominated next of kin, she did not have the
authority to change the funeral director after arrangements had been made by
his named next of kin. I consider this to be reasonable in the circumstances.
I regret that the man’s sister felt that she was treated rudely and suggest that
the Governor or family liaison officer considers whether an apology would be
appropriate.
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CONCLUSION
120. The man had been recalled to prison after breaching the terms of his licence.
In spite of being familiar with the prison environment, he clearly had a difficult
time. This stemmed mainly from his own actions in dealing in contraband. He
became fearful of other prisoners to whom he owed money and made
allegations of bullying. He was also accused of bullying others.
121. On more than one occasion, the man harmed himself and admitted he had
done so to get his own way. Nevertheless, staff put in place monitoring
procedures. However, they did not consider it appropriate to accede to his
request to be segregated partly because of the increased isolation that this
would entail.
122. I concur with the clinical reviewer’s conclusion that staff could not have
foreseen that the man would make a serious attempt to take his life. They
initiated relevant action to monitor him when he harmed himself or threatened
to do so, but there were some shortcomings in the way that procedures were
taken forward. In particular they did not assess the deterioration in the man’s
state of mind and behaviour the day before he took his life.
123. The misconduct of the officer has been carefully investigated by the prison
Service and the Lincolnshire Police and there is no substantive evidence to
prove that it led to the man’s decision to take his life.
124. I do not consider that these failings necessarily led to the man’s death but
they should be addressed to improve safety for other prisoners. It is clear
from the letter left by the man that his fear of reprisals from other prisoners
weighed heavily on his mind and it is possible that these worries affected him
so greatly that he took the decision to end his life.
125. Finally, I regret that the man’s family were not entirely satisfied with the
conduct of all the prison staff. I hope that they are reassured that their views
have been taken seriously and steps will be taken to avoid any repetition. My
investigator gave her initial feedback to the Governor of Lincoln, when she
attended to obtain documentation and the further statement from Senior
Officer B.
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RECOMMENDATIONS
To the Primary Care Trust and Head of Healthcare:
1. The Governor and Primary Care Trust should advise healthcare staff that an
entry should always be made in the continuous clinical record when a patient is
prescribed an antidepressant drug. Patients on antidepressant drugs should be
assessed at regular intervals, not less than monthly and entries should be made
in their clinical record following each assessment.
Accepted. The prison service say that a record is kept of all prescribed
medication and that information is input onto the electronic patient record system.
They say that all patients on anti-depressants are regularly reviewed by a
healthcare professional and information is input into the patient electronic medical
record.
To the Governor:
2. The Governor should reinforce to staff that all ACCT documentation should be
fully completed and that objectives set in the CAREMAP should be achievable
and realistic.
Accepted. The prison service say that robust daily and weekly management
checks are completed by residential managers to fully comply with ACCT
documentation. Orderly officers complete a daily check of ACCT documentation
and have to sign and stamp each document once they have verified and agreed
that the document is to the required standard.
3. The Governor should ensure that additional ACCT reviews are carried out
following significant events, such as a prisoner’s behaviour deteriorating and that
those reviews should be conducted as a multi disciplinary function, embracing the
expertise of specialist staff such as the healthcare team, chaplaincy and others.
Accepted. The prison service say that all managers are fully aware of the need
to instigate additional reviews when required and appropriate including a
significant event or change in behaviour. There may be a requirement during the
night state that the multi-disciplinary review be conducted in the morning
depending on the circumstances but this is evaluated on a case by case
scenario. If this is deemed appropriate, observations are increased and
recorded.
4. The Governor should ensure that all staff who have contact with prisoners are
given an appropriate level of ACCT training.
Accepted. The prison service say that ACCT awareness training is scheduled
through the monthly training days and staff are identified to attend.
5. The Governor should ensure that sufficient staff are provided to monitor prisoners
subject to suicide and self-harm procedures and adjust the staffing levels to take
account of the number of active ACCT plans.
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Accepted. The prison service say that Wing Managers ensure that the
appropriate level of staffing and support is available and that extra staff are
deployed to a wing if there are a high number of ACCTs open.
6. The Governor should remind staff to seek appropriate medical assessments if a
prisoner displays signs of a marked deterioration in their physical or mental
condition.
Accepted. The prison service say that this is discussed as part of the ACCT
training and induction. There are already embedded procedures for alerting the
PCT and/or Mental Health staff should there be deterioration in the prisoners’
mental or physical condition. Mental Health training is also offered to staff.
Clinical leads are now allocated to each wing; nurses are office based in E wing
as this is the nearest central location.
7. The Governor should remind all staff of the procedures when serious self-harm or
suicide occurs and an ambulance is needed.
Accepted. The prison service say that a Governor’s order will be issued on an
annual basis reminding staff of the reporting codes for a medical emergency and
the details that are required in order for the control room to provide information to
the ambulance service.
8. The Governor should ensure that prisoners at risk of suicide or self-harm who
require but do not have access to tobacco because they are on the basic regime
are assessed by appropriate staff and consideration is given to providing nicotine
replacement.
Accepted. The prison service say that this does take place. A referral for
assessment by a nurse or GP could be made at any time.
9. The Governor should ensure that prisoner complaints are investigated at the
earliest opportunity as per Lincoln’s Request and Complaints procedure and
within the timescales set out in the policy. Prisoners who make a complaint
should be kept informed of its progress.
Accepted. The prison service say that the Request and Complaints procedure
has been reviewed and operates to both the PSO and local policy. All complaints
are logged and monitored for response dates and copies are delivered back for
each prisoners. Prisoners can request further copies if necessary and progress
is tracked and reported should an interim response be given in the first instance
pending further investigation.
10. The Governor should ensure that after any incident of serious self-harm, staff are
invited to attend a hot debrief, carried out under the guidelines of PSO 4710 and
that relevant staff are able to attend. All staff involved in an incident of serious
self-harm should be offered the services of the staff care team.
Accepted. The prison service say that the death in custody contingency plan
was reviewed in September 2010 and highlights the requirement of the Duty
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Governor to arrange for a hot debrief to be held and that staff care team services
are offered.
Family response to draft report
The man’s family raised a number of issues in response to the draft report. They
remain very concerned about the level of care afforded to the man and believe that
staff actions played a part in his death. In particular, they raised concerns about:
• The length of time it has taken to complete the report.
• The lack of a substantive link between a prison officer’s conduct and the
man’s death.
• The lack of a full mental health assessment the day before the man died.
• How the ACCT process was managed and risk assessments made.
• How interviews with prisoners were carried out at the beginning of the
process.
• The man’s medication, in particular mirtazepine.
• That there was no mention of a postal order that was sent by the man’s father.
• There were some factual inaccuracies, which have been amended.
The family urge the Governor to ensure that existing policies are followed carefully
and recommendations made are acted upon to prevent further deaths in the prison.
They believe that had the proper procedures been followed, the man’s death might
have been prevented.
The family sent a further letter in response to the report, which relates to clinical
matters. I decided that there were no grounds to extend the investigation further as
It would not add to the current conclusions. However, I have attached the letter as
an annex to this report, with a view to the issues contained in the letter being
addressed at the inquest.
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