Individual at Doncaster

Investigation into the circumstances surrounding the
death of a prisoner at HMP & YOI Doncaster
on 21 June 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2011
This report considers the circumstances of the death of a 49 year old man, a
prisoner at HMP & YOI Doncaster. The man was found hanging in his cell at 5.00pm
on 21 June 2010. His cellmate had discovered him when he returned from an
education class and alerted staff. The staff and another prisoner removed the
ligature that was round his neck and administered cardio pulmonary resuscitation
(CPR). This continued until the arrival of nursing staff who had been alerted via the
emergency radio, and paramedics were also called. Despite the efforts of both
prison healthcare staff and paramedics, the man was pronounced dead at 5.39pm.
A senior investigator conducted the investigation on my behalf. I would like to thank
the Director of HMP & YOI Doncaster and his staff for their co-operation and
assistance with the investigation. A review of the medical care afforded to the man
while in custody, was completed independently on behalf of my office.
The man was on remand at Doncaster and had recently been told that he was likely
to face further more serious charges. He had been in prison before and was familiar
with the regime. On reception, he told nursing staff that he had been previously
treated for depression and he was taking antidepressants, but a referral to the
mental health services was not made. Apart from treatment for a hand injury
sustained during his alleged offence, he had little contact with the medical team at
Doncaster. On the day of his death he told staff that he had a migraine and asked to
stay in his cell during the afternoon, where he was eventually discovered by his cell
mate.
I have made three recommendations. These concern referrals for mental health
assessments and the absence of prescription charts and recording of medication,
the other is for the Director to commend the prisoner who assisted staff in the
resuscitation attempts. I conclude that staff could not have reasonably foreseen his
actions and took the appropriate steps to resuscitate him once he was found,
regrettably without success. All three recommendations have been accepted by
HMP/YOI Doncaster.
Jane Webb
Acting Prisons and Probation Ombudsman April 2011
2
CONTENTS
Summary 4
The investigation process 5
HMP Doncaster 6
Key events 8
Issues 13
Conclusion 17
Recommendations 18
3
SUMMARY
The man went into prison on remand at HMP & YOI Doncaster on 12 May 2010. He
was 49 years old. This was not his first time in custody or indeed at Doncaster.
During his initial health screen, he told the nurse that he was receiving anti-
depressant medication, but denied any thoughts of self-harm or suicide. An injury to
his hand sustained during his alleged offence, prompted a referral to the prison
general practitioner (GP), but no further assessment of his mental well-being was
completed.
While living on the residential unit, he mixed with a select group of friends, but would
openly engage with staff and talk about general things. He raised no concerns
during these conversations.
On 14 May, the police visited the prison in order to discuss further matters with him,
but he refused to see them. He then received a letter from his solicitor telling him
that he was going to be charged with further offences at his next court appearance.
Neither the police nor the solicitor alerted the prison to the charges. These charges
were more serious and might make him a potential target for other prisoners. He
was aware of the significance of the charges, and talked about his concerns in a
telephone conversation with a friend. Despite his concerns, he did not share them
with staff.
On the afternoon of 21 June, he told staff that he had a migraine and asked to stay in
his cell rather than go to education. There was no reason for staff to think that he
had an ulterior motive for wishing to remain in his cell, and there were no
requirements for him to be checked during the afternoon.
Prisoners began to arrive back from work at around 5.00pm. A Prison Custody
Officer (PCO) opened the cell door to allow the man’s cellmate in. When the
cellmate went into the cell, he said “he’s gone” and walked back out of the cell. At
this point, another prisoner who had been close by went into the cell, which was
dark. He immediately asked the PCO to pass her cut down tool (which is issued to
every member of staff so that they can safely remove ligatures), and released the
ligature attached to the man’s neck. The PCO used her radio to call for medical
assistance, and with the help of the prisoner and another member of staff, moved the
man on to the floor of the cell. Staff, assisted by the prisoner who removed the
ligature started cardio pulmonary resuscitation (CPR), which was continued by
healthcare staff. Following the radio call by the PCO, an ambulance had been
requested and arrived at 5.15pm. Paramedics continued to treat him and attempt to
resuscitate him, but he was pronounced dead at 5.39pm.
After the man’s death, a hot debrief was held and support provided for staff and
prisoners. The Deputy Director and Assistant Chaplain went to the home of the
man’s ex-wife to break the news and answer initial questions.
4
THE INVESTIGATION PROCESS
1. A senior investigator was appointed as the investigator on 22 June, and made
contact with the Head of Internal Affairs at the prison, who provided liaison with
my office. The investigator arranged for the man’s prison and medical records
to be made available. Notices were issued to staff and prisoners informing
them of the investigation and inviting anyone who had information about the
death to contact the investigator. No responses were received.
2. The investigator visited Doncaster on 24 June to formally open the
investigation. He met senior staff and discussed the case with them. He also
collected the relevant documentation.
3. During the course of the investigation, the investigator interviewed three
members of staff at Doncaster and spoke to one prisoner. He also wrote to
another prisoner who had been released from custody, but received no
response. Following the investigation, the investigator provided feedback on
his findings to the Director, both verbally and in writing.
4. The man was examined by healthcare staff at Doncaster in relation to an injury
to his right hand which he had sustained before he went into custody. Apart
from this, he had limited contacted with healthcare staff. An independent GP
undertook a complete review of the medical care afforded to the man while in
custody, on behalf of my office.
5. One of my family liaison officers (FLO), wrote to the man’s ex-wife and she
responded by telephoning on 15 July. The FLO explained the purpose of the
investigation and provided the family with the opportunity to ask questions or
raise any concerns for consideration as part of my investigation. The FLO was
also contacted by the man’s sister regarding questions that the family wish to
be answered. They are summarised as follows:
• How did he die?
• Was he alive when he was found by prison staff?
• Why had he been remanded and was he facing other charges?
• Why was he not subject to any suicide or self-harm monitoring?
6. The investigator has investigated the concerns raised by the family as well as
other issues. I hope that my report provides the family with more clarity of the
time he spent in prison and the events leading up to his death.
7. The investigator also contacted the Coroner to inform him of the nature and
scope of the investigation. He asked for a copy of the post mortem report to be
made available when completed. The Coroner provided the report which
concludes that the cause of the man’s death was fatal upper airway obstruction,
which would be in keeping with ‘hanging’.
5
HMP & YOI DONCASTER
8. HMP & YOI Doncaster is a privately run prison operated under contract by
Serco. It opened in 1994 as a local prison, originally graded to hold the most
dangerous of prisoners (category A). It was reclassified to a category B prison
in May 2003. Prisoners are risk assessed when they come into prison and
given a category based on their offence and the risk that they pose to the public
should they escape. There are four levels of category: 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.
9. The Governor of a private prison is referred to as a Director. The contract
between the National Offender Management Service and the prison is
monitored by a controller appointed by the Ministry of Justice.
10. The prison is certified to hold up to 771 prisoners, but has recently had an
operational capacity of 1,145. It consists of three houseblocks, each made up
of four separate two level wings. In addition to the residential units the prison
also has a two floor healthcare unit and a segregation unit.
11. At the time of Mr Johnson’s death, the last inspection of the prison by HM Chief
Inspector of Prisons had been carried out in February 2008. The report of this
inspection said:
”… On our return for this unannounced full follow-up inspection, we
found improvements in a number of areas, but also a worrying
deterioration in healthcare and little progress in expanding purposeful
activity …
“… Staff prisoner relationships remained generally sound, and
managers had embarked on a culture change programme among staff
to reinforce expectations …
“… Doncaster has addressed a number of the criticisms that we made
on our last visit, and continued to make good progress in areas such as
resettlement. However, there is much still to do, not least to ensure
that safety is maintained and the serious deficits in healthcare urgently
addressed …”
A further unannounced inspection of Doncaster took place in November 2010.
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12. The Independent Monitoring Board (IMB) at Doncaster also published a report
in September 2009. The Prisons Act 1952 and the Immigration and Asylum Act
1999 require every prison and immigration centre to be monitored by an
independent board. The members are appointed by the Secretary of State for
Justice from members of the community in which the prison is situated.
Doncaster IMB’s report concluded:
“… The Board continues to feel that all prisoners should be engaged in
purposeful, meaningful activity each day and though recognising this is
difficult to achieve in what is a local prison with a high turnover of
remand prisoners it remains a concern.
“The prison is fortunately a modern and flexible establishment whose
physical build is advantageous and helps the process of coping with
difficult situations, from incidents to overcrowding. This is in no small
part due to work of its staff that has served the prison well in the period
and continues to do so …”
13. My office was given responsibility for investigating all deaths in custody in 2004.
Since then there have been three previous investigations into apparent self-
inflicted deaths. Recommendations made following these investigations are not
repeated in this report.
7
KEY EVENTS
14. The man was arrested on 9 May 2010. On his arrest, he had an injury to his
right hand sustained during the alleged offence of assault. Once in police
custody he was seen at Barnsley District General Hospital. He was examined,
but this was not concluded due to his aggressive behaviour. The police
recorded that he was alcohol dependent. He had not consumed alcohol for a
few days, until the day before his arrest. No concerns about self-harm were
recorded.
15. The man was prescribed medication for pain relief and taken to Sheffield
Northern General Hospital under police escort, where the injury to his right
hand was operated on. Following the operation, he returned to the police
station on 11 May. He appeared at Barnsley Magistrates Court the following
day where he was remanded into custody until 18 May.
16. Following his court appearance, he was taken to HMP Doncaster. All new
prisoners are given a health screening and on his arrival a nurse interviewed
him. The clinical assessment forms completed while in police custody were
sent to the prison and passed to the nurse. The nurse recorded that he had
been in custody previously and was last released from HMP Lindholme. All the
medication that he had been receiving in police custody and prescribed by the
hospital was recorded. When asked about his alcohol consumption, the man
said that he only drank socially, but had used cannabis in the last month.
17. As part of the health screen, the nurse asked him about his mental health
history. He said that he had previously been treated for depression and
prescribed the antidepressant, trazadone. The reception health screen
indicates that he brought this medication into prison with him and the clinical
reviewer was told that the drug was dispensed to the man while he was in
custody. Traces of trazadone were found by the toxicologist following the post
mortem. When asked about self-harm, he said that he had no history of trying
to harm himself in prison custody, but nothing is recorded about any history
outside custody. The man reiterated to the nurse that he had no feelings about
harming himself while in custody.
18. Following the initial health screen, a secondary screening was completed. The
secondary screening provides more depth on both previous and family medical
history. Again, the man’s depression was recorded, as well as no family history
of chronic illness. He told the nurse that he expected to have support from his
ex-wife while in custody. He was referred to the prison GP due to the injury on
his right hand. He also gave consent for information to be shared with other
support agencies working in the prison and for his medical notes to be obtained
from his community GP. There is no documentary evidence to show that any
information was requested or received from an outside GP.
19. As with all new prisoners coming into custody, a cell sharing risk assessment
(CSRA) was completed. The purpose of a CSRA is to identify any potential
risks that may arise from placing prisoners in shared accommodation.
Homophobia, racism and unpredictable violent behaviour are some of the
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indicators that staff try to identify. Once completed, the staff assign a level of
risk to a prisoner based on their answers to the questions, and they decide
whether the individual is suitable to share a cell or not. During the CSRA, he
raised no concerns that would place him at high risk of harm to a cellmate, but
he did say that he had been subject to self-harm monitoring while in prison in
2008, for 24 hours. In addition to questions asked by staff on the CSRA, staff
will also access a prisoners pre-convictions from the police national computer,
and any relevant information will be used in the CSRA process.
20. The prison GP, assessed the man on 13 May, recorded the injury to his right
hand and arranged for the dressing to be changed frequently. The doctor also
recorded that medication should continue to be prescribed as indicated in the
hospital’s discharge letter, there is no prescription chart and no indication when
this medication was prescribed or by whom.
21. Within the medical documentation provided to the investigator, there was a
referral to the community mental health team at the prison. It had been
completed in February 2008, for him, during a previous sentence. The referral
indicates that he was possibly suffering from depression and had been
prescribed medication to treat this. However, the community mental health
team did not consider the man to require their input, and he was referred back
to the primary care mental health nursing staff. It is not clear whether the nurse
who conducted the health screen on his most recent reception was aware of
the previous referral or whether it would have made any difference to the
actions taken, but it does show that concerns about depression had been
raised previously at Doncaster.
22. The man began his induction (the process of introducing new or newly
sentenced prisoners into custody) on 13 May, but only completed the first day
due to his hand injury. On the same day, he was also seen by the CARATs
(Counselling, Assessment, Referral, Advice and Throughcare services) team
and an assessment completed. (Organisations specialising in the treatment of
substance abuse have drugs and alcohol workers based in most prisons.
CARATs workers can run programmes, offer counselling, support and referral
to rehabilitation centres to prisoners and on release.) He disclosed that he had
smoked a small amount of cannabis daily for the last 20 years, and hoped to be
able to stop the habit. He also said that he was aware that his paranoia had
increased over recent years, and that he suffered from bi-polar disorder. When
he experienced episodes of mania, he would use cannabis to bring himself
down. The CARATs worker explained the health risks associated with
cannabis and provided Mr Johnson with leaflets detailing the risks. It was
recorded that no further intervention was required.
23. After completing his induction, the man moved from the induction landing to
another residential wing on 18 May. He also appeared via video link at
Barnsley Magistrates Court the same day and was subsequently remanded into
custody until 15 June. While on the residential wing, little is documented about
him. However, he was seen by nursing staff on a number of occasions
throughout the remainder of May, for his dressing to be changed and eventually
9
the stitches removed. No concerns about any other medical problems were
recorded, and he never raised concerns with the Mental Health Team.
24. On 14 May, the police visited Doncaster in order to question him on other
matters, but he refused to see them. He then appeared via video link again at
Barnsley Magistrates Court on 15 June, and was further remanded until 22
June. On the wing, the man continued to cause no concern to staff who
described him to the investigator as a ‘model’ prisoner. On 16 June, he began
attending education where he participated in entry level numeracy classes.
25. His solicitor wrote to him on 18 June, to tell him that the Crown Prosecution
Service (CPS) intended to charge him with further offences arising from the
original offence, and they would form part of the hearing on 22 June. The letter
did not detail what the new charges were, but it is understood that they were
known to him. (Correspondence between prisoners and their legal
representatives is confidential and so the contents of the letter would not have
been known to prison staff.)
26. The investigator listened to telephone calls made by the man whilst he in
prison. All calls made by prisoners are recorded, but only those of prisoners
who are subject to legal restrictions are routinely monitored. The man had no
such restrictions. He spoke to his friend on 19 June, and said that he had
received a letter from his solicitor that indicated that he was to be charged with
sexual assault. During the conversation, he told his friend that he was in the
wrong place for charges like those to “come out”. However, during the call he
sounded in good spirits and asked about the times and channels of television
programmes.
27. Staff interviewed during the investigation said that the man was quite a talkative
individual who would speak to staff on the wing. He would sometimes talk
about his case, but never indicated that he had any particular concerns. Over
the weekend of 18/19 June, he had a visit from his friends and at lunchtime on
21 June, he made another telephone call to his friend to ask whether they had
got home safely. His friend asked him whether he had cheered up, and he
replied “no, not really”. His friend then told him that there was light at the end of
the tunnel, and he replied ”what light”. They then talked about what he had
eaten for lunch and his friend told him that he needed to eat more as he was
losing weight. The man’s friend then told him to not do anything “daft”, and he
replied “forgive me if I do”. His friend responded by telling him not to talk like
that and the man said that it was “the only way he could see out of it”. They
also discussed the breakdown of his relationship during the calls and the fact
that his ex-partner was the alleged victim.
28. After lunch, at around 3.00pm, prisoners were unlocked from their cells to
attend work and education. The man approached a PCO and said that he felt
unwell, and had a migraine. The PCO told the investigator that he asked the
man if he was alright, and he replied ”yes, I am just going to lie down in my
cell”. The officer said that there was nothing to indicate that he should be
concerned about him.
10
29. The PCO added that, during each week day afternoon, staff go to every cell to
deliver breakfast packs to each prisoner. Breakfast packs contain cereal, a
carton of milk, tea bags and sometimes a bread roll, jam and butter. They are
provided between Monday and Friday when prisoners are not unlocked for
breakfast. The PCO said that, given the man had indicated that he had a
migraine, staff would have tried not to disturb him. They would have opened
his door slightly and placed the breakfast packs inside. The man was not
subject to any special monitoring, such as suicide prevention or to prevent
escapes, and as such there was no reason for him to be checked during the
afternoon.
30. Prisoners returned from work and education just before 5.00pm. Another PCO
was on duty on house block 3 and escorted the man’s cellmate to his cell.
When interviewed, the PCO said that she unlocked the cell as she normally
would and noticed that it was “exceptionally dark”, which was unusual. She
also noticed that there was a towel hanging over the end of the bunk bed down
to the floor. The PCO explained that there were curtains at the window, which
prisoners are able to purchase from the prison canteen. (The prison canteen
enables prisoners to purchase goods including food, toiletries and other items
that have been approved by security, using money that they have earned in
prison or have been sent by family or friends.)
31. The PCO said that when she opened the door the cellmate went into the cell
and she heard him say something like “he’s gone”. At that point, another
prisoner who had been standing close by, went into the cell. The PCO said that
she did not go into the cell at this point, but then the prisoner who had entered
called to her and asked her to pass him her cut down tool. (All prison staff
carry a tool that is designed to cut ligatures.)
32. The investigator said to the PCO that it seemed unusual for a member of staff
to hand a cut down tool to a prisoner, and asked her why she had done this.
She explained that her first instinct when the prisoner asked for her cut down
tool was to pass it to him as if he was asking for it then there was obviously a
problem. She added that as the cell was dark she could not actually see the
man, but could see the prisoner cutting something. He then passed the tool
back to her. The PCO said that she had also radioed for medical assistance.
She does not recall indicating a code, but the healthcare staff and another PCO
who responded recall that a code blue emergency call was made. (Doncaster
operates an emergency code system - code blue means a person is not
breathing and code red means there is a blood injury).
33. In a statement written after the man’s death, the prisoner who had entered the
cell and cut the ligature, said that when he went into the cell the man was lying
on his bed with his arms by his side. His weight was supported by a ligature
around his neck that was made from torn bedding. He asked the PCO to pass
her cut down tool, cut the ligature and then removed it from the man’s neck. He
later made an amendment to his statement in which he alleges that the PCO
had frozen when she realised the man was hanging and he had to ask her for
her cut down tool. The prisoner also said in his amended statement that he
considered that the PCO could have acted quicker. The investigator spoke to
11
the prisoner when he visited Doncaster. The prisoner told him that, at the time
everything happened really quickly and, on reflection, he felt that the PCO had
acted appropriately. He also said that the man’s death had affected him and he
was now seeing medical staff at Doncaster who were providing support.
34. A fellow PCO told the investigator that he was on the wing and locking up other
prisoners when he heard the emergency call over the radio. He then called to
the PCO at the cell. She called back to tell him where she was and he made
his way to there. He said that when he got to the cell, the man was still lying on
the bed and he helped the PCO and the prisoner move the man on to the cell
floor. The PCO said that, once the man was on the floor, the prisoner
automatically began cardio pulmonary resuscitation (CPR) by giving mouth to
mouth breaths. The PCO carried out chest compressions. They were joined
by another PCO who took over from the prisoner in administering mouth-to-
mouth breaths.
35. Both PCO’s continued the resuscitation attempts until the medical staff arrived
bringing medical equipment with them, including a defibrillator. A defibrillator is
a device that can be used when a person has gone into cardiac arrest. The
machine monitors for any electrical output from the heart and a voice prompt
instructs medical staff whether to continue with resuscitation. If there is output
the machine will deliver an electric shock to try and get the heart into a normal
rhythm. However, a defibrillator will not restart a heart that has no output.
36. Nursing staff continued to deliver CPR until paramedics arrived at 5.15pm. The
paramedics took over CPR and continued to administer treatment until 5.39pm,
when they pronounced the man dead.
Following the man’s death
37. Following the man’s death, a member of the staff care team at Doncaster, was
contacted at home and came into the prison. He spoke to the staff involved as
well as the prisoner who had assisted. He also spoke to prisoners who were
subject to suicide and self-harm monitoring.
38. A hot debrief was held with the staff who were involved in trying to resuscitate
the man. Arrangements were made for his cellmate to be given support as well
as the prisoner who had helped staff. Staff involved were also offered support
with travelling home, and the chaplaincy team told them that they were
available to give support to staff and prisoners. The Deputy Director and
Assistant Chaplain, arranged to visit the man’s next of kin to inform them of his
death.
39. As with all deaths in custody, the police were notified and attended at 7.09pm.
They visited the cell and removed what appeared to be a suicide note
addressed to the man’s ex-partner. A copy of the note was given to the
investigator. In the note, the man addressed his personal feelings towards his
ex-partner and told her that he still loved her.
12
40. The prison staff arrived at the home of the man’s ex-wife, who he had named
as his next of kin, at 8.05pm. When they broke the news, she was upset and
concerned as to how she would break the news to their daughter. A neighbour
was invited round to support her and the man’s parents were also asked to
come and help break the news to the daughter.
41. The Deputy Director told the man’s ex-wife what was known about her ex-
husband’s death at that time and the various investigations that would take
place. She declined the invitation to visit the prison and the Deputy Director
told her that the offer would remain open, she also reassured her that the
prison would assist with funeral costs if she wished.
13
ISSUES
Clinical care
42. When the man arrived at Doncaster, a reception health screen was completed.
The screen recorded that he was receiving medication for depression and this
continued while in custody. It was also recorded that he had been treated for
depression in the community. The clinical reviewer highlighted this element of
the screening in his assessment of the man’s clinical care:
”… A positive answer to this question prompts a referral for a mental
health assessment. There is no evidence that such a request was made
to the Mental Health Team. When seen by the GP on 13 May 2010, no
reference to his mental health or review of his medication was made …”
43. The clinical reviewer goes on to say in his review that:
“It can be argued that any interaction between a clinician and a patient
contains an element of mental health assessment, but there is no
evidence of this having happened even at an informal level …”
44. Within the documentation provided to the clinical reviewer and my investigator
is a copy of a mental health referral for the man from a previous sentence at
Doncaster in 2008. In relation to this, the clinical reviewer says:
“A copy of a Mental Health referral and assessment from 2008 is in the
bundle. This raises no immediate concerns in its own right but if taken in
conjunction with the current prescription of a substantial dose of anti-
depressant could have prompted further assessment of the man’s mental
state, at primary care level if nothing else …”
45. In view of the comments made by the clinical reviewer in relation to referrals to
the mental health services and the information provided by the man on his
reception, I make the following recommendation:
The Head of Healthcare should ensure that, if a prisoner discloses a
mental health condition on reception, or if evidence of such a condition
comes to light in the accompanying documents, staff should refer them to
the appropriate agencies and ensure that a full mental health assessment
is carried out.
46. The reception health screen is designed to be completed in two stages. Again,
the clinical reviewer makes reference to this in his report:
“The Health Screening Tool was designed to be done in two stages.
The first part on reception and the second part, two to three days later.
The man’s screen was all completed on the same day. This is not a
criticism, merely an observation …”
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47. In concluding his review, the clinical reviewer says:
“From the records, there is nothing that flags up a high risk of suicide,
but the man was receiving a substantial dose of an anti-depressant and
had been referred to the prison GP. The GP focused on his hand
injury, but one might respectfully suggest that a review of medication
was appropriate at that time. This might have raised concerns.
“Equally the instruction that a mental health assessment should be
prompted by a positive response to Q8 and Q9 was not carried through
and again such a referral might have thrown up concerns.
“With the reservations expressed above, I have no grounds for thinking
that the man’s care fell short of what was appropriate …”
I make no formal recommendation abut the absence of a medication review, but
trust that the Head of Healthcare will consider whether staff need to be
reminded of the potential value of such a review.
Clinical records
48. The investigator was provided with documentation relating to the man by the
prison and this included his medical notes, however, no prescription chart was
present. It is documented that he was to be prescribed medication, which is
understood to have been pain relief for a hand injury. The clinical reviewer in
his report says that he was told that he would have been continued on his anti-
depressant medication, but without a prescription chart, this cannot be
confirmed. In view of this I make the following recommendation:
Not recording drugs as they are prescribed is a breach of medical
guidelines and The Head of Healthcare must ensure that prescription
charts are completed as required and that notes are not just made in the
ongoing medical record.
Additional monitoring
49. The man’s family asked why he had not been subject to closer monitoring. The
facts gathered during the investigation have found that the further charges he
was facing were causing him concern and he had voiced his concerns to a
close friend on the telephone. However, he had not shared them with staff, and
those charges would not have been known by the prison until he went to court
on 22 June. It would not be normal practice for either the police or solicitors to
share information about a prisoners charges with a prison, unless there was
particular concern about an individual’s well-being. The man had not raised
concerns with either his solicitor or the police.
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Response to finding the man
50. When it became apparent that the man was hanging and in need of immediate
medical attention, staff reacted quickly. However, the investigator questioned
the appropriateness of the PCO passing her cut down tool, which could be
used a weapon, to a prisoner for him to release the ligature. When interviewed,
it became clear that the PCO’s reasons for doing this were well intentioned and
instinctive. During discussion, she recognised that in hindsight this may not
have been the most appropriate thing for her to do. The PCO is fully aware of
why this was inappropriate, and I therefore make no recommendations on this
matter.
51. The clinical reviewer considers the resuscitation attempts to have been
appropriate. These situations are traumatic for everyone involved and in this
instance, a prisoner initially took part in attempting to resuscitate the man. The
prisoner concerned, told my investigator that since the death he had suffered
some anxiety, but was now being offered support by the healthcare team at
Doncaster. Prisoners are not expected, and indeed do not expect themselves
to have to resuscitate a fellow prisoner, and his actions should be commended
by the Director of Doncaster.
The Director of Doncaster should commend the prisoner’s actions in
assisting staff in trying to resuscitate the man.
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CONCLUSION
52. The man had been in custody for only a few weeks when he took his own life.
Despite the fact that a referral to the mental health services was overlooked
when he arrived into custody, no other concerns about his well-being were
raised by staff or himself while on the residential unit. He was familiar with
prison routine and described by staff as a prisoner who kept himself to himself,
but would happily talk to staff if he had concerns or just for a chat. The
description provided by staff would indicate that no concerns were raised about
him being either low or depressed, in his interactions with them.
53. The evidence is that he had suffered with depression in the past both in the
community and on a previous sentence at Doncaster. The correct procedures
for both following up his disclosure on reception with a referral to the Mental
Health Team should have been followed, but it is understood that this is unlikely
to have resulted in him being placed onto their case list.
54. The investigation has found that the charges that the man was facing would
have carried with them the potential for him to be singled out by other
prisoners. He was aware of them and referred to this in a telephone
conversation with a friend. Undoubtedly, the charges, and potential stigma
attached to them and the breakdown of his relationship would all have been
weighing heavily on his mind.
55. On 21 June, he was unlocked to attend education. He told a member of staff
that he was going to remain in his cell, as he had a migraine. The PCO had no
reason to disbelieve him or consider that there may be an ulterior motive for
him not wishing to go to education. The man was not on any special monitoring
and, during the course of the afternoon, there was no reason for him to be
checked.
56. The actions that unfolded after he was discovered are already detailed, but a
note left by him indicated his intent to end his life, citing the reason for doing so
as the breakdown of his relationship with his partner and ongoing court matters.
I judge that given the information available to them and the man’s general
demeanour, staff could not have predicted that he would take this action and
when he was found, they made every effort to resuscitate him.
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RECOMMENDATIONS
1. The Head of Healthcare should ensure that if a prisoner discloses a mental
health condition on reception, or if evidence of such a condition comes to light
in the accompanying documents, staff refer them to the appropriate agencies
and ensure that a full mental health assessment is carried out.
2. Not recording drugs as they are prescribed is a breach of medical guidelines
and The Head of Healthcare must ensure that prescription charts are
completed as required and that notes are not just made in the ongoing medical
record.
3. The Director of Doncaster should commend the prisoner’s actions in assisting
staff in trying to resuscitate the man.
The recommendations made in my report have been accepted and actioned by the
Director and Acting Clinical Director at HMP/YOI Doncaster.
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