Individual at Brixton

Investigation into the death of a man
whilst in the custody of HMP Brixton in March 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2009
This is a report of an investigation into the death of a 39 year old man. This was not
his first time in prison. He was found hanging in his cell at HMP Brixton having been
at the prison for less than 24 hours.
I would like to offer my sincere condolences to his family for their loss. I hope that
my report addresses the concerns that they have raised.
The investigation was carried out on behalf of the Ombudsman by my investigator. I
must apologise for the length of time taken to produce the report. This is clearly
unacceptable and no doubt caused additional anxiety to his family at an already
difficult and sad time. A final clinical review which was commissioned to consider his
healthcare whilst he was at Brixton was not received until 2 June 2009. However, I
would like to thank the clinical reviewer for his thorough and full review. I would also
like to thank the Governor of Brixton and his staff for their assistance with my
investigation.
The man had a history of harming himself, depression and alcohol and drug
dependency. In addition to these concerns, the sexual offence with which he was
charged should have been a trigger for him to be considered at risk of harm. Of
course I cannot say that he would have lived if a suicide and self harm monitoring
had been opened, but staff would have been alerted to the possible risk. A note he
left in his cell said that he was not guilty of the charges and wanted his name to be
cleared.
On a more positive note, I am impressed by the induction arrangements for new
prisoners at Brixton and the care and professionalism shown by staff who tried to
resuscitate him. However, it is unfortunate that the family liaison arrangements at
the prison were less effective, and his family found them unhelpful.
I make eight recommendations to the Governor, five of which are also directed to the
Head of Healthcare. This is not the first time I have made recommendations to
Brixton regarding reception, healthcare assessments in reception and the role of the
Family Liaison Officer at the prison.
The version of my report, published on my website, has been amended to remove
the names of the woman/man who died and those of staff and prisoners involved in
my investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman October 2009
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CONTENTS
Summary
The Investigation Process
HMP Brixton
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was found hanging in his cell at HMP Brixton. He had been at the prison
for less than 24 hours. He had previously spent time at Pentonville prison, but had
been released on licence in 2007.
He had a history of harming himself, depression and alcohol and drug use. He had
scars on both forearms where he had previously cut himself. He spent 11 days in a
psychiatric hospital in 2007. Just over a month before he arrived at Brixton, he took
a drug overdose and was admitted to Queen’s Hospital, Romford. He told prison
staff that he was currently receiving medication for his depression and blood
pressure.
The reception officer who first interviewed him said he did not realise he was
charged with a sexual offence, despite it being highlighted on the Prisoner Escort
Record (PER) form completed by the police. The man himself said he was in prison
for breach of bail. The reception officer did not consider opening an Assessment,
Care in Custody and Teamwork (ACCT) for him (a tool used to monitor prisoners at
risk of harming themselves or of suicide).
The man next saw the acting head of healthcare. She too said that she did not
realise the nature of his charges, even though she herself had written it on the front
of the First Reception Health Screening form. The acting head of healthcare did
discuss the man’s history of depression, his previous attempts to take his life and his
alcohol and drug dependency. However, he told her he had no intention of harming
himself now and she made a judgement that it was not necessary to open an ACCT.
She completed the secondary health screening for him at the same time.
The man was then seen by the prison doctor who prescribed medication for alcohol
withdrawal. The doctor asked healthcare to check the medication and the dosage
that the man said he was prescribed by his community doctor. He would not
prescribe him any other medication until this information was obtained.
After the man completed the reception process, he was taken to a cell on C wing and
settled in for the night. It was a shared cell, but the man’s cell mate was transferred
off the wing early the next morning. Sometime in the morning the man was given
another dose of alcohol withdrawal medication.
Later that morning the man attended an induction course for new prisoners. The
officer who ran the course recalled that he participated fully, asked questions and
showed an interest in the library visit that afternoon. In the meantime, healthcare
continued to make the necessary checks with his community doctor to confirm the
medication he had been prescribed for depression and blood pressure.
The man returned to his cell at lunchtime. Around 2.00pm, the first officer on the
scene unlocked him to collect him for the afternoon induction session. She got no
response when she called out and could not see him, so she asked an officer on the
wing where he was. When she was told he was in his cell, she returned and looked
through the observation panel which shows the cell toilet area. The officer thought
that the man was looking out of the window. She went inside and asked why he had
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not responded a few minutes earlier. As she again got no response she went into
the toilet area and saw him hanging from a bed sheet which appeared to be tied to
window bars.
Staff responded quickly to the emergency call and carried out Cardio Pulmonary
Resuscitation (CPR) until the paramedics arrived. Despite their efforts, the man was
pronounced dead at 3.07pm.
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THE INVESTIGATION PROCESS
1. The investigation was conducted on behalf of the Ombudsman by my
investigator. On her initial visit to HMP Brixton she met staff and visited the
cell where the man had died. Notices were issued to staff and prisoners
informing them of the investigation and inviting anyone with information about
his death to contact her, but no witnesses came forward.
2. My investigator reviewed the man’s prison and health records in addition to
the police’s Prisoner Escort Record (PER) form. Interviews were conducted
with 14 members of staff over several different dates, 13 June, 24 July, 4
September and 6 October 2008.
3. The Ombudsman commissioned a clinical review from Nina Murphy
Associates LLP on behalf of Lambeth Primary Care Trust (PCT). The clinical
reviewer accompanied my investigator to Brixton on 6 October to interview a
member of healthcare staff who saw the man on his reception into the prison.
4. My family liaison officer contacted the man’s family to explain the purpose of
the investigation and invite them to raise any concerns they wished to be
considered. A meeting was arranged with his family’s solicitor on 23 July
2008. My investigator, my family liaison officer, the man’s daughter and her
mother attended. A number of issues were raised which included:
• Whether the man had been on any medication?
• Why the man was not on “suicide watch”?
• Whether he was asked about any mental health problems or health
concerns on reception?
• Whether any member of staff had seen scars on the man’s forearms and
identified a possible risk and in particular whether staff were aware that the
man had previously been on an ACCT?
• Whether any previous prison records would have arrived at Brixton while
the man was there?
• Whether he had been in a single cell?
• What the man had used as a ligature and how he had done this and how
long it had been before staff discovered him?
• Whether police records would be accessed to see if there had been any
concerns about the man whilst he was in police custody and what
concerns were passed on to the prison?
• If the fact that the man had been questioned about child abuse allegations
was a factor in his death?
• Concerns about the effectiveness of the prison’s Family Liaison Officer.
I hope that this report helps the man’s family better understand what
happened to him in the time leading up to his death.
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HMP BRIXTON
5. HMP Brixton is a local Victorian prison dating back to 1819, serving a number
of courts in South London. It holds both sentenced and remand prisoners
with a high daily turnover. The prison can hold up to 798 prisoners within four
main residential units and a healthcare inpatient facility.
6. Since the Ombudsman began investigating deaths in custody in 2004, there
have been 14 deaths at the prison, both from natural causes and self inflicted.
In 2005 I made recommendations regarding reception procedures and
healthcare assessments in reception. In 2006 I made a recommendation
regarding the Family Liaison Officer and returning the deceased property to
the family, although these do not necessarily impact on this case.
Her Majesty’s Chief Inspector of Prisons (HMCIP)
7. Brixton was most recently inspected by HMCIP during a full unannounced
inspection in April and May 2008. The Chief Inspector said in relation to new
prisoners arriving at the prison:
“ … The environment in reception is poor, although staff treated new
arrivals properly. First night procedures were satisfactory, but not all
prisoners received an induction."
8. With regard to reception, first night procedures and induction, the report says:
“ … The reception area had recently been redecorated and cleaned, but it
remained cramped and oppressive, with some very poor holding rooms.
Staff were, however, respectful towards prisoners and aimed to move
them through reception as quickly as possible.
“ … Since our last inspection, the first night centre had been moved to
better accommodation on C wing. A recently introduced Insider peer
supporter scheme was benefiting new arrivals. The arrangements to
identify the cell locations of new arrivals required improvements, and some
new arrivals had not received entitlements such as a shower or reception.
“ … A two-day induction programme began the morning after a prisoner’s
arrival, with contributions from officers, Insiders and representatives from
key departments. The content was generally good and useful, but
attendance was variable and record keeping poor. Not all prisoners who
needed to attend a full induction actually did so.”
9. Finally, with regard to a member of healthcare assessing a new prisoner:
“ … New arrivals were seen by a member of the healthcare team for a first
night health assessment. Referrals were made to other services, such as the
mental health in-reach team, as required.”
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10. In respect of self-harm and suicide at Brixton, the report says:
“… There had been seven self-inflicted deaths in the previous two years.
Initial assessments for prisoners at risk were good, but care maps and
ongoing care were sometimes rushed and carried out in isolation. The
suicide and self-harm strategy was up to date. Meetings were well
focused, multi-disciplinary and strategic. The environment made it difficult
to manage and distract vulnerable and at-risk prisoners.”
11. The Chief Inspector also commented:
“… Suicide and self harm structures were satisfactory, but the quality of
self- harm monitoring documents varied.”
.
Independent Monitoring Board (IMB)
12. An IMB is appointed to each prison by the Secretary of State for Justice. Its
members are 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 areas of
concern.
13. The most recent report for the period 1 July 2007 to 30 June 2008 makes the
following observations regarding the first night centre and induction
procedures:
“… Since July 2007 induction has been held in its new room on C wing. C
Wing also holds first nighters and Rule 45 prisoners. Interviews are held
as soon as prisoners arrive in the prison and thereafter they are
transferred to C wing which is also the holding wing, until prisoners are
transferred out. Staffing levels, compared with some other wings, are
reasonably good. The packs for new prisoners are generally more
complete than this time last year, although pillows are still regularly
missing from them.
“… Induction takes place Monday to Friday and includes presentations
from the IMB, Chaplaincy and the Education Department. Prisoners
receive information about sending and receiving mail, parcels, reception
visits, canteen and telephone calls, the use of the library, substance
misuse and other relevant information…”
14. With regard to reception procedures and the nursing assessment of a new
prisoner, the IMB says:
“… The demands on the time of staff in reception continued to be
problematic. They work intensely in the morning and late in the evening
when the vans depart and return.
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Further the nurses who meet each prisoner to carry out a medical check,
take a history and perform risk assessments, seem to do a tremendous
amount of work in very little time available to them. The best nurses are
used for this important job and the Board commends this practice.”
Assessment, Care in Custody and Teamwork (ACCT)
15. ACCT requires any member of staff who identifies concerns about a prisoner
at risk of harming themselves or of suicide to take action and record those
actions. Within 24 hours of the ACCT document being opened, the prisoner is
seen by an assessor and has a case review meeting. ACCT reviews are held
at appropriate intervals and are attended by the prisoner and a case manager,
together with other members of staff including a representative from
healthcare.
Anti-ligature knives
16. Anti-ligature knives, also known as ‘fish-knives’ are designed to cut ligatures.
All staff who have contact with prisoners must be provided with, and carry on
duty, their own personal knife.
Canteen
17. This is the prison shop where prisoners can buy or order goods each week to
a limited value. It mostly sells food, confectionery, stationery, toiletries and
tobacco products.
Listeners and Insiders
18. The prison has a Listener scheme which is a system where the Samaritans
train selected prisoners to be the first contact for any prisoner who is feeling
vulnerable or at risk. The scheme is confidential and any prisoner can ask to
speak to a Listener at any time. The prison also runs an Insider scheme.
Insiders are experienced prisoners who help new prisoners settle into prison
life and answer any questions.
Rule 45
19. Prison Rule 45 relates to the separation of prisoners for either the good order
of the prison or for the protection of vulnerable prisoners.
Telephone calls
20. Prisoners have access to telephones on the wing. Each prisoner is given a
unique PIN number to access their account and are only able to dial
authorised numbers.
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KEY FINDINGS
21. On 15 March 2008, the man was arrested for an alleged sexual offence and
taken to Limehouse Police Station. At 6.15pm it was reported by a police
medical officer that he had “the illnesses of high blood pressure, phobia and
depression. A history of previous attempts on own life”.
22. However, an assessment was carried out by a police sergeant who said that
the man was not suffering from any physical or mental condition at the time.
23. Just over 15 minutes later, a medical review was undertaken by a doctor,
which mentioned that the man had a history of chronic alcohol dependence,
hypertension and depression. He was receiving sertraline 200mg daily (a
drug prescribed for depressive illness and obsessive-compulsive disorder),
carbamazapine 200mg in the morning (prescribed for varieties of epilepsy and
prophylaxis of bipolar disorder) and atenolol 50mg daily (prescribed for raised
blood pressure). The doctor noted that the man had consumed alcohol that
morning and had taken an overdose ten weeks previously. The medical
advice for the man was “close supervison”.
24. The following day (a Sunday) a note was made on the Prisoner Escort Record
(PER) form that the man had both a medical and mental health condition. He
had been arrested for a sexual offence (this was circled on the PER) and
there were concerns about self harm and suicide. The police did not tick the
appropriate box on the PER to record that he had drug/alcohol issues.
However, the police recorded further information about his risks, which were
as follows:
“High blood pressure and phobia
Suffers from depression
Arrested for a sexual offence
Previous attempts on own life
Violence markers on PNC (Police National Computer).”
25. The next day, the man was taken from Limehouse Police Station to Thames
Magistrates’ Court. Part B of the PER form shows that he was regularly
spoken to by police custody officers to check that he felt okay. At 5.01pm he
left Thames Magistrates’ Court (where he had been remanded) en-route to
Brixton prison. The PER form accompanied him there.
26. The man arrived at Brixton prison later that day. The process for a new
prisoner at Brixton is that they are met by a senior officer (SO) in reception
who checks the documentation which has accompanied them and books in
their property. The prisoner is then searched and asked to sign for the
property he is allowed to retain and for that which is stored. They are then
taken to a holding room where they wait to be escorted to C wing, the wing for
new prisoners. It is there that the prisoners are interviewed by a reception
officer and a member of healthcare.
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27. The reception officer who saw the man recalled interviewing him on the
evening of 17 March. He could not remember how many new receptions
arrived that night, but thought it was in the region of 30 to 60. He recalled that
the man was given something to eat and drink before he interviewed him.
The reception officer confirmed that at this interview an officer would have a
prisoner’s file in front of them which would include the PER form, however he
would not have records from a previous time in custody. The officer could not
remember which documents he had when he interviewed the man. (However,
the officer indicated on the Cell Sharing Risk Assessment that he had
received the man’s PER, court warrant and pre-convictions.)
28. The reception officer remembered that the man had seemed okay, but
apprehensive. He explained to the officer that he was on licence recall for
common assault and breaking licence conditions by not staying at an agreed
address. The reception officer said he was unaware that the man had
actually been arrested for a sexual offence (as stated on the PER form and
warrant). He said that the interview would have followed the same lines,
although he might have offered the option of Rule 45 status if he knew about
the sexual offence. The reception officer said that he could see the man had
a lot of old cuts to his arms and the man said that he used to harm himself
when he was younger. The officer asked if he had any thoughts or intention
of harming himself again or in the future. The man replied that he did not.
The reception officer asked him whether he had any suicidal thoughts and the
man again repeated that he did not. The man said he just wanted to get his
time in prison over and done with and be released.
29. A Cell Sharing Risk Assessment (CSRA) was also completed during this
interview. On the CSRA, the officer wrote that the man was in custody for
common assault, had abused alcohol or drugs and was currently dependent
on drugs or alcohol. He had been on a 2052SH (the Prison Service’s self
harm and suicide document, which was later replaced by ACCT) previously,
although was not at that time. The man told the reception officer that he did
not want to share a cell with a drug user, that he used to self harm in his
twenties but had no intention of doing so again. The man was assessed as
being of medium risk to others and no concerns were noted.
30. The reception officer said that he explained the prison’s Listener and
Samaritans schemes and told the man that if he felt he needed to speak to
someone, he could ask. Once the interview concluded, the reception officer
took the man back to the holding cell and passed his file to a member of the
healthcare team who was situated in the next room.
31. The acting head of healthcare who carried out the first reception health screen
who saw the man was the prison’s acting primary care manager. The acting
head of healthcare carried out the First Reception Health Screen which
determines a prisoner’s general health or mental health concerns. She said
that at this screening the member of healthcare staff might not have the
prisoner’s entire file but would have their basic details such as name, date of
birth, and perhaps their holding warrant. She also said that sometimes she
would see the accompanying PER form.
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32. Due to the acting head of health care’s absence from the prison, some seven
months elapsed between the man’s death and the interview for this
investigation. She did not recall whether she had seen the PER form.
However, on the front of the health screening form, she had written, under
current charge ‘sexual act/Bail Act/common assault’, indicating that she must
have been aware of the sexual offence he was charged with. The acting head
of healthcare said that she would probably have interviewed the man about
his depression and his medical problem, but would not delve far into the
details of his offence.
33. The acting head of healthcare took details of his doctor she noted that he had
been in prison before and the amount of alcohol, and frequency, that he
drank. Question 13 of the screening form asks whether the prisoner might
consider harming themselves and requires the member of healthcare to
record their impression of the prisoner’s behaviour and mental state. The
acting head of healthcare ticked ‘no’ against whether the man would consider
harming himself and ticked a box to indicate there was ‘nil of note’. She
agreed with the interviewer that, on reflection, it would have been useful to
have noted that the man appeared to be withdrawing from alcohol.
34. The man confirmed that he had been treated by a psychiatrist outside of
prison for anxiety and depression and gave details of a psychiatric hospital he
stayed in for 11 days in 2007. The acting head of healthcare said in interview
that she did not explore with the man the circumstances of his admission to
psychiatric hospital the previous year. He also gave her details of the
medication he had been prescribed for mental health problems which was
sertraline and olanzipine.
35. The man told the her that he had tried to harm himself on 8 February 2008 by
taking an overdose of a month’s prescribed medication (although it is unclear
whether these were anti-depressants or blood pressure tablets) and was
admitted to Queen’s Hospital. This was just over a month before he arrived at
Brixton. She did not refer the man for a mental health assessment (contrary
to current guidance) nor did she open an ACCT document. (Mental health
referrals normally take place quite quickly, within two or three of days.) She
recalled that the man said he did not want to harm himself at any stage but
just wanted help for his alcoholism and his medication. She indicated that the
man should be referred to the doctor regarding his physical health and for
substance misuse, and also referred to the drugs service.
36. Although the acting head of healthcare knew about the man’s mental health
issues, recent overdose, the scars on his arms and his history of harming
himself, and his substance misuse, she said that she used her judgement
based on his responses to her questions. She said that he clearly stated that
he had no intention of harming himself and that the overdose had been a “silly
mistake”. The acting head of healthcare completed the screening form by
saying that the man was fit for normal location (on C wing for induction), for
work and for single cell occupancy and that he had been referred to see the
doctor.
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37. The acting head of healthcare then completed the second part of the CSRA
(begun by the reception officer who had interviewed the man). She told my
investigator that the CSRA was used to determine whether a prisoner is a risk
to another prisoner if they shared a cell. She agreed with the officer’s
assessment that the man was a ‘medium’ risk, meaning that he was no
immediate risk to others but that the situation needed to be reviewed
regularly.
38. The secondary health assessment is the second part of the health screening,
which should be carried out one or two days after the first reception health
screening. However, on this occasion, however, it was completed by the
acting head of healthcare immediately after the first assessment. She
explained that both assessments are carried out at the same time at Brixton.
Nothing of note was recorded on the secondary health assessment, simply
the man’s weight and height, questions about smoking and cessation and
hepatitis and other diseases.
39. The man then saw the prison doctor. The prison doctor noted that the man
had Alcohol Dependency Syndrome. The man told the prison doctor that he
was prescribed carbamazepine 600mg and sertraline 200mg and was unsure
of his blood pressure medication. As these are high doses, the prison doctor
needed to confirm the amounts with the man’s community doctor and so
asked healthcare to follow it up. The doctor prescribed one month’s supply of
atenolol 50mg to be taken daily, although it is not clear whether the
medication was to be held in the man’s possession or to be administered by a
nurse. (The clinical reviewer wrote to the prison doctor on 31 December
2008. One of the questions he asked was what impression he gained from
the man’s history of taking carbamazapine and sertraline, especially in terms
of a possible diagnosis, and in terms of any special precautions which he
considered should be put in place in relation to the man’s medical care. The
prison doctor did not answer this question in his response of 28 January. The
clinical reviewer also asked what information was available to the prison
doctor when he saw the man. The prison doctor replied that he did not have
access to any previous medical history, nor any screening documents.)
40. On a document entitled “Alcohol Detox Regime – High Dose” there is an entry
to show that the man was given 40mg of chlordiazepoxide whilst in reception
and a further 40mg the following morning. This is a librium detoxification
regime - librium is a tranquilliser and can be used to prevent symptoms of
alcohol withdrawal. It says underneath the medication ‘56x10mg+14x5mg,
but it is unclear to what this refers. The man was also prescribed one month’s
supply of vitamin B strong compound and thiamine (B1 vitamin complex)
100mg, which he was permitted to keep in his possession.
41. There is a medication plan on the form as well which shows that the man was
due to be given 40mg of chlordiazepoxide three times a day on 18 and 19
March, reducing to 35mg on 20 March and 30mg on 21 March. (This
medication would be dispensed by healthcare staff.).
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42. Following the healthcare assessment, the man was taken to his cell on C
wing, the prison’s induction wing, and allocated into a shared cell for the night.
The man would have been given an opportunity to shower and to have an
evening meal. The rest of the night appeared to pass quietly and there is no
record on any prison documentation of his cell bell being pressed or any
alarm being raised.
43. At some point during the morning of the incident, the man was seen by a
nurse from the Substance Misuse Team. She only had available to her a list
with the man’s name and the substance he abused. He told the nurse that he
had been free from alcohol for the last three days (since the day he was
arrested). He spoke about his history of depression and the medication he
had been taking. The nurse told my investigator that the man had seemed
‘bright’ and gave her no cause for concern.
44. The nurse from the Substance Misuse Team recorded on the Substance
Misuse Clinical Assessment Form that had been at HMP Pentonville in 2007.
He was not asked to give a urine sample as he was detoxing from alcohol.
On the Substance Misuse Care Plan, the nurse advised the man about the
detox programme, recommended that he should be given chlordiazepoxide as
already prescribed by the prison doctor, and referred him to Duel Diagnosis, a
team who deal with prisoners who have a history of mental health problems.
(The man died before he was seen.)
45. By this time the man was alone in his cell, as his cell mate had been moved
off of the induction wing earlier that morning. At around 10.00am he was
collected from his cell to attend the wing’s induction, held by the first officer on
the scene.
46. The first officer on the scene told my investigator that induction is held for new
prisoners who have not been at Brixton within the last three months.
Prisoners attending the two day induction are unlocked at 10.00am. The aim
is to familiarise them with the prison on their first day and to carry out an
education assessment on the second day, when they are also told about
housing and benefits. On the first morning, the first officer on the scene said
they spoke to the prisoners about ACCT, Insiders and Listeners,
adjudications, court appearances and telephone calls. They also explained
how to use PIN phone, visits, having money sent in to them and how to buy
canteen and their property.
47. The first officer on the scene recalled that the man sat at the front of the room
during the induction, actively took part and asked for clarification about
anything he was not clear about. He asked how much money he could spend
a week on canteen and how he arrange for money to be sent in. At the end of
the morning’s induction, the officer explained that she would come to collect
them for the afternoon session at around 2.30pm when that they would go
through some other parts of the induction, including a visit to the library. The
man asked whether he could take books out straight away and she replied
that he could do so. The officer said that the man seemed to be interacting
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quite normally and gave her no cause for concern. All the prisoners then
returned to their cells for lunch at approximately 11.45am.
48. Lunch is served to prisoners in a bag, which they take back to their cells. The
man would have collected his lunch between 11.45am and 12.30pm and then
returned to his cell. He would then have been locked in until the second
officer came to collect him for the afternoon’s induction at 2.30pm.
49. During the morning the first nurse on the scene sent a fax to his doctor in the
community, at the Harold Hill Healthcare Centre in Romford, to establish what
medication he had prescribed to the man. A copy of the fax shows that the
nurse sent the letter to the community doctor at 12.15pm. At 2.06pm the
community doctor’s surgery sent a faxed response. The community doctor
confirmed that the man was transferred out of the practice on 5 March 2008
and was last issued medication on 30 January 2008 which included sertraline
200mgs daily, atenolol 50mgs daily and carbamazepine 500mgs a day.
50. After lunch, at approximately 2.00pm, the first nurse on the scene went to an
afternoon briefing for staff. She collected up her induction list and began to
go to the cells to call the prisoners for the afternoon induction. When she
arrived at the man’s cell she opened the door. Two cells are knocked into one
with a separate toilet, and the door shut off from the main part of the cell. The
first officer on the scene went into the main part of the cell and shouted for the
man. She got no response and shut the door.
51. The first officer on the scene saw the second officer on the scene on the
landing and asked him if he knew where the man was. The second officer on
the scene replied that the man was in his cell. The first officer on the scene
returned to the man’s cell (it was now approximately 2.20pm) and looked
through the observation panel which enabled her to see the toilet area. She
could see the man’s back and thought that he was looking out of the window
into the exercise yard.
52. The first officer on the scene went into the cell and asked the man if he had
heard her call out. There was no reply and she pulled open the toilet door
and saw that the man had what appeared to be a sheet tied around his neck
and his face was purple in colour. The first officer on the scene ran outside
the cell and called the second officer on the scene and a third officer on the
scene for assistance. (The first officer on the scene told my investigator that
she had not asked for a radio when she started duty that morning, because
she was working ‘family friendly’ hours and, by the time she arrived, there
were usually no radios left.)
53. The second officer on the scene, who had been unlocking other prisoners on
the landing, went inside the man’s cell almost immediately after hearing the
first officer on the scene’s call. The second officer on the scene could see
that the man was hanging from a ligature in the toilet area which he had
attached to the bars of the window. The second officer on the scene was
closely followed into the cell by the third officer on the scene.
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54. The second officer on the scene used his anti-ligature knife (fish knife) to cut
the ligature, whilst the first officer on the scene supported the man. The
officers laid the man on the floor of the cell with his legs towards the toilet and
his upper body towards the main cell area. The first officer on the scene
recalled that the man’s eyes were open and appeared to be glazed, his
tongue was protruding and his face was a blueish colour. The second officer
on the scene thought that the man looked as though he had already died.
The third officer on the scene, who did not have a radio either, shouted out an
emergency Code One call (the call means that a person is not breathing and
alerts healthcare staff that they are required to attend immediately). The third
officer on the scene did not hear the emergency call being put out over the
radios, but within a few seconds members of staff from healthcare were at the
cell. She then left the cell.
55. The SO was alerted to the emergency over his radio. A Code One call was
put out, which alerts healthcare staff to a life threatening incident. The first
nurse on the scene and the second nurse on the scene also heard the
emergency call. The first nurse on the scene collected two bags of
emergency equipment to take with her. One bag contained medication and
the other bag held suction machines, oxygen, a mask and a defibrillator. (The
first nurse on the scene took the bags from healthcare, she confirmed at
interview that there is an emergency bag containing oxygen and a blood
pressure machine on each wing.)
56. In the meantime, the second officer on the scene had checked the man for
signs of life. He could not get a response, and so he and the first nurse on
the scene commenced Cardio-Pulmonary Respiration (CPR). The second
officer on the scene began chest compressions and the first nurse on the
scene attempted to give mouth to mouth, using a face mask that she had with
her, but she had difficulty putting the mask on the man as she had not used
one before. The first officer on the scene said in interview that she did not
have current first aid training. (They intended to work at a ratio of two breaths
to every 15 chest compressions.) Before the first officer on the scene could
apply the mask correctly, members of healthcare arrived.
57. The first nurse on the scene and the second nurse on the scene took
approximately two minutes to get to the man’s cell. A third nurse who also
held a radio, was already in the cell. He was giving mouth to mouth
resuscitation with the second officer on the scene still administering chest
compressions, when the two nurses arrived. The second nurse on the scene
recalled that at some point he took over the chest compressions. The acting
head of healthcare, who also heard the call, arrived shortly afterwards.
58. The SO (a certified resuscitation trainer) was directed to C wing and then to
the man’s cell. He recalled that the man was lying on the floor with his legs in
the toilet area and his upper body in the main part of the cell. He asked the
nurses what checks they had made for signs of life and preceded to carry out
his own. The SO checked that the man’s airway was clear and felt for a
pulse. No pulse was found so the nurses continued CPR. The SO took over
chest compressions from the second officer on the scene and worked with the
16
third nurse. The first nurse took the oxygen and mask out of one of the
emergency bags and passed them to the third nurse. By this time officers
had left the cell to make room for the healthcare staff.
59. The SO applied the pads of the defibrillator to the man’s chest. The machine
instructed the SO to shock him. The SO explained during his interview that a
defibrillator instructs a shock when heart movement is detected. The SO
delivered a shock to the man and continued with CPR. However, the next
reading two minutes later showed that the man was asystole (meaning there
was no cardiac output). The SO said that the first reading might have been
incorrect as a nurse may still have been touching the man (as opposed to
standing clear). However, he could not be sure of this.
60. The SO took a bag valve mask from the emergency bag, to help administer
breaths into the man. (This is a mask which is placed over the mouth and
oxygen from the bag is administered by squeezing it.) The SO also inserted
an oro-phayngeal airway, which keeps an airway open down to the windpipe.
The SO gave the man two breaths using the bag of oxygen. He noticed that,
although the man’s chest was not rising, his stomach was. (This can be an
indication that a person’s windpipe has been crushed whilst they were
suspended. Air cannot pass into the lungs, but passes through to the
oesophagus and into the stomach instead.) The SO stopped the breaths and
continued with compressions only. At this point he noticed that the man was
very pale, was cold to the touch and was cyanosed (a blue tinge to the skin
which indicates a lack of oxygen in the blood). The SO used the defibrillator
to assess whether the man should be shocked again, but this time no shock
was advised.
61. A nurse (it is not clear which) palpated the man’s abdomen (palpation is an
examination technique) causing him to vomit. The SO had to use the suction
unit to clear the man’s throat from obstruction. CPR was continued, although
The SO said he could tell that this was unsuccessful and he thought that the
man had already died.
62. The acting head of healthcare recalled that staff continued to administer CPR
until the paramedics arrived at 2.35pm. The paramedics checked the man
for signs of life using their own equipment. After about ten minutes they
decided that CPR was no longer advisable and left the cell.
63. The SO and the acting head of healthcare gathered up their equipment and
the cell door was sealed at 2.41pm. The officers who had been on the scene
and the first nurse on the scene went to the Governor’s office suite to await a
visit from a member of the Care Team and write an incident report. The Head
of the Care Team, spoke to the staff who had been involved in the discovery
and resuscitation of the man, but not the healthcare staff. (At that time, he
was the only Care Team member at the prison so it was fortunate that he was
on duty, although he was contactable on his mobile telephone in an
emergency.) The second nurse on the scene went back to healthcare and the
SO went off duty. The nurse who had done the first reception screen said that
an informal de-brief was held in healthcare.
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64. At 3.07pm the duty doctor arrived and pronounced that the man had died.
The cell was re-sealed. In the meantime, staff tried to establish the man’s
next of kin details. There was no address on file, so the prison contacted the
police for assistance. The man’s daughter was located at 3.58pm.
65. A note was recovered from the cell and handed to the police when they
arrived at the prison at 4.10pm. The note, written by the man but undated,
said that he was innocent and could not live with people thinking he might
“have done such a thing”. He asked that his name be cleared as he was not
guilty. At some point that afternoon the undertaker arrived to take the man to
the mortuary, but my investigator could not find a record of what time this
occurred.
66. Just after 4.00pm, the duty governor (who no longer works in the Prison
Service) the family liaison officer, and the governor’s secretary (who had
experience of being with a care team at another prison) left Brixton to travel to
the man’s daughter’s house. The family liaison officer told my investigator
that he had held the family liaison role for almost two years and had attended
a two day FLO training course. They did not telephone ahead to the man’s
daughter as the Governor’s secretary said they did not have a number for her.
(However, a mobile telephone number is recorded on the first page of the
core record.)
67. The Governor’s secretary said that they arrived at the house between 6.00pm
and 6.30pm to break the news to the man’s daughter. When the prison staff
got there, she was not alone, but had her baby and her partner with her. The
duty Governor and the family liaison officer explained that the man had died.
The family liaison officer was unclear in interview about what information he
actually provided. (When my investigator met with the man’s daughter and
her mother at their solicitors on 23 July 2008, she was told that staff did not
seem to know much about what had happened and could not give her much
detail. She said it would have been helpful if they had more information,
ahead of their visit to her.)
68. The family liaison officer told my investigator that he had not given the man’s
daughter information regarding the prison’s contribution to funeral costs
because he did not want to overload her with information. It seems that she
found out this information from the Coroner rather than the prison (and the
prison reimbursed the cost some time after the man’s family had to pay for the
funeral in full). He did not pass on the details of the Coroner either, although
he had this information. The family liaison officer was unaware of the
requirement to maintain a Family Liaison Officer’s Log. He was also unaware
of a booklet produced by the Coroner about what to do when someone dies.
69. The family liaison officer gave the man’s daughter his details and his mobile
telephone number and took numbers for family members. However, the SO
said during his interview that the family had some problems contacting him in
the prison, as he was no longer authorised to carry a mobile telephone.
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(Mobile telephones are no longer permitted in prison for any reason.) The
man’s family did have difficulty contacting the family liaison officer.
70. At 6.30pm a hot de-brief was held at the prison. (This is an opportunity for all
the staff who were involved in the man’s death to discuss what had happened
and any issues rising as a result). It was chaired by the governor and
attended, amongst others, by five governors, the SO, officers and nurses who
had been on the scene. The governor explained that some of the staff who
had been involved in the man’s death had already gone home, but were
spoken to before they left the prison.
71. One issue raised at the de-brief on behalf of the first officer on the scene, was
that she had been unsure about how to use the breathing mask and
highlighted this as a training issue. Another governor said that the
paramedics had arrived 11 minutes after being called, although staff’s
perception was that it had seemed longer.
72. There is no record of a critical incident de-brief being held. (The de-brief
should have been held a month or so after the man’s death to give staff the
opportunity to discuss what had happened and how they are feeling). The
staff interviewed by my investigator did not receive an invitation to attend one.
A member of the Care Team) said that he checked on staff the following day.
He said that prisoners would have been reminded of the services of Listeners
and Samaritans. The first officer on the scene said that a note explaining why
the regime had been disrupted was circulated to prisoners. The third officer
on the scene said that all prisoners who were on ACCTs were assessed and
the second officer on the scene recalled that at least two prisoners had
ACCTs opened for them because of their concerns after the man’s death.
73. The second nurse on the scene said that nobody from the Care Team had
contacted him at any time after the man had died, but that he had not
contacted them either. He said he would have found it helpful to talk to a
member.
74. Representatives from the prison did not attend the man’s funeral, although
The SO told my investigator that he offered to do so. A problem encountered
by the family was the delay in receiving the man’s belongings. There
appeared to be some difficulty locating his property (although my investigator
understands that it has now been returned to his family).
75. A post mortem was held on 2 April 2008 at Greenwich Public Mortuary which
confirmed that the man died as a result of hanging.
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ISSUES
Support for the man
76. Despite information about the man’s vulnerability recorded on the PER form
which accompanied him to Brixton, neither the reception officer nor the acting
head of healthcare said that they noticed that he had been arrested for a
sexual offence. Given that information and the additional comment on the
PER that the man had made previous attempts on his life and suffered from
depression, they should have considered providing additional care and
support for him, which may well have included opening an ACCT.
The Governor and Head of Healthcare should issue urgent guidance to
staff who meet a prisoner on reception, to follow the guidance in the first
reception healthcare screening forms, in respect of mental health
assessments.
77. I understand that an ACCT cannot and should not be opened for every new
reception or for every prisoner charged with a sexual offence, but in the man’s
case I would have thought that there was enough information to suggest that
he presented a risk to himself. I know that the man told staff that he had no
thoughts of harming himself, but given the combination of his self harm
history, the nature of his alleged offence,, his alcohol dependency, his
withdrawal from alcohol and his depression, I believe that closer supervision
would have been a sensible precaution.
The Governor and Head of Healthcare need to ensure that all staff are
aware of all different types of triggers which may lead a prisoner to harm
themselves, and of their responsibility to open ACCT’s when necessary
and to make referrals to the mental health service where appropriate.
78. I, of course, cannot say that if the man had been on an ACCT it would have
prevented him from taking his life. Nevertheless it is essential that reception
staff read and properly evaluate the information contained in the PER form.
The Governor should remind reception staff to read and properly
evaluate the information in the PER form.
79. I also recommend that staff admitting a prisoner into reception or carrying out
a health screening ensure they have as much documentation as possible with
them when seeing the prisoner. The clinical reviewer also comments that
more emphasis should be placed on the documentation containing a
prisoner’s past history, to enable informed decisions and less reliance on self
reporting by prisoners.
The Governor and the Head of Healthcare should ensure that a system
is in place so that staff in reception and those carrying out the health
screening have all the relevant documents and past history about a
prisoner whilst making their assessment.
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Next of Kin details
80. The core record, which is also completed in reception, merely noted the man’s
daughter’s name and telephone number as his next of kin details. This
caused a delay while staff tried to obtain her address to allow the FLO to visit.
The omission may have been because it was the only information the man
knew or was willing to pass on. I make no recommendation here, but suggest
that the Governor reminds staff of the need to obtain as much information at
reception as possible.
Health screening
81. The acting head of healthcare carried out the man’s first and secondary health
screening at the same time. A secondary health screening should be
conducted one or two days after the initial screening, to allow prisoners the
time to adapt to their surroundings and raise any issues which they may not
have considered when they first came to the prison.
The Governor and Head of Healthcare should ensure that a secondary
health screening is carried out by healthcare one or two days after the
initial health screening in reception. This should allow time for a
prisoner to raise any issues of concern or difficulties they may have.
First aid training
82. The first officer on the scene and the second officer on the scene should be
commended for their prompt actions after discovering the man, in releasing
the ligature and in beginning resuscitation. However, none of the staff who
arrived at the cell in the first instance had up to date first aid qualifications.
Neither did they work to the new ratio of breaths to chest compressions which
is 30 to two, rather than 15 to two. The first officer on the scene also said she
did not know how to use the mask for administering mouth to mouth
resuscitation. Prison training records show that only ten non-healthcare staff
were currently first aid trained at the time of the man’s death.
The Governor and Head of Healthcare should ensure that training needs
of all discipline staff are reviewed, to include up-to-date first aid training
and use of first aid equipment.
Family liaison
83. The prison’s FLO, although trained and experienced in the role, did not
appear to handle this case particularly well. According to the family, he was
not fully appraised of the circumstances of the man’s death before he visited
them. He was unable to pass on important information regarding a
contribution to the funeral expenses, the whereabouts of his property and
arrangements for viewing the man at the mortuary. The FLO was also
unaware of the need to complete a Family Liaison Log, which is an important
document used by prison FLOs nationwide.
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The Governor should ensure that prison FLOs are aware of current
practice and provide full and accurate information for the bereaved
family.
Care Team
84. At the time of the man’s death there was only one official member of the Care
Team. Fortunately he was contacted by mobile telephone and was able to
come to the prison. My investigator was told that this situation had been
remedied since then, and more members have now been trained and joined
the Care Team.
Critical incident de-brief
85. A critical incident de-brief does not appear to have been held. It is important
that staff who are involved in an event such as this are given continuing
support and the opportunity to discuss what happened with others who may
also have been affected. Whilst a hot de-brief (which did take place) is helpful
in that it is held the same day, a critical incident de-brief is generally held a
few weeks afterwards and gives staff time to consider what happened and
how they are feeling.
The Governor should ensure that a critical incident de-brief is always
held after a death in custody.
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CONCLUSION
86. The man had been in prison before, but on this occasion he was charged with
a sexual offence. The police had highlighted on the PER that, as well as the
nature of his offence, he was at risk because he had a history of depression
and of harming himself. The reception and healthcare staff who saw the man
when he first arrived at Brixton both said they were unaware of his offence
and believed he had been returned to prison as he had breached his bail.
The nurse who did the first reception screen, however, must have been aware
of the allegations against the man, as she recorded the charge on the front
sheet of the First Reception Health Screen form.
87. Given the allegations against the man, his history of depression and his
history of harming himself, I would have expected more care to have been
taken when interviewing him in reception. Although staff have to accept what
a prisoner tells them, and in this case the man said he had no intention of
harming himself, there are other signs they must look out for, such as the
scars on his forearms. I know that it is not possible for an ACCT to be opened
for every new prisoner, and nor should it be, but I believe the combination of
these factors should have alerted staff that the man may have been at risk of
harming himself.
88. During his brief time at Brixton, the man seems to have been treated well. I
was impressed with the induction arrangements and the speed with which
healthcare confirmed his medication details. I am also pleased that the man’s
medication for alcohol withdrawal and blood pressure were started
immediately. These are all examples of good practice.
89. I was also impressed by the action of staff who attempted to resuscitate the
man. They worked professionally and calmly until the paramedics arrived and
should be commended for this.
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RECOMMENDATIONS
To the Governor and Head of Healthcare:
1. The Governor and Head of Healthcare need to ensure that all staff are aware
of all different types of triggers which may lead a prisoner to harm themselves,
and of their responsibility to open ACCT’s when necessary and to make
referrals to the mental health service where appropriate.
2. The Governor and Head of Healthcare should issue urgent guidance to staff
who meet a prisoner on reception, to follow the guidance in the first reception
healthcare screening forms, in respect of mental health assessments.
3. The Governor and the Head of Healthcare should ensure that a system is in
place so that staff in reception and those carrying out the health screening
have all the relevant documents and past history about a prisoner whilst
making their assessment.
4. The Governor and Head of Healthcare should ensure that a secondary health
screening is carried out by healthcare one or two days after the initial health
screening in reception. This should allow time for a prisoner to raise any
issues of concern or difficulties they may have.
5. The Governor and Head of Healthcare should ensure that a cross section of
discipline officers have up to date first aid qualifications and are able to use
first aid equipment such as face masks.
To the Governor:
1. The Governor should remind reception staff to read and properly evaluate the
information in the PER form.
2. The Governor should ensure that prison FLOs are aware of current practice
and provide full and accurate information for the bereaved family.
3. The Governor should ensure that a critical incident de-brief is always held
after a death in custody.
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