Individual at Belmarsh

Investigation into the death of a man
at HMP Belmarsh in May 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2011
This is a report into the death of a man who was found hanging in his cell in the
Segregation Unit at HMP Belmarsh.
I would like to offer my sincere condolences to his family for their loss. I hope my
report addresses the concerns that they have raised.
The investigation was carried out by one of my investigator, with assistance at some
interviews by another investigator. I must apologise for the length of time taken to
produce this report and the additional anxiety caused to the man’s family at an
already sad and difficult time. The clinical review which was commissioned to
consider the man’s health care and mental health care was not received until the end
of January, which added to the delay. However, I would like to thank them for their
thorough and full review. I would also like to thank the Governor of Belmarsh and his
staff for their assistance with the investigation.
The man was received into HMP Highdown on 6 May 2010. He had a history of
harming himself and of depression and mental health issues. Two days later the
man was discovered making a ligature from a television wire. He told staff this was
not a serious attempt to harm himself, but a cry for help. On 10 May the man was
transferred to HMP Belmarsh after appearing at the Central Criminal Court. He was
initially taken to a normal wing, then transferred to healthcare and then to the
Segregation Unit, due to his behaviour. I make criticism of his transfer to
Segregation as he had been assessed as not suitable to be held there only a few
hours previously. Due to his history of attempting to harm himself, the man was
subject to suicide and self harm monitoring procedures. However, he was
discovered in his cell, suspended from a ligature on 13 May, and all attempts to
resuscitate him sadly proved unsuccessful.
I make nine recommendations to the Governor, the Head of Healthcare and to both
jointly. These surround locating vulnerable prisoners in the Segregation Unit, self
harming procedures, receiving important correspondence into the prison, first aid
equipment, and clinical records and the standard of record keeping.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Nigel Newcomen CBE
Prisons and Probation Ombudsman December 2011
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CONTENTS
Summary
The investigation process
HMP Belmarsh
Key Events
Issues
Conclusion
Recommendations
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SUMMARY
1. The man was found hanging in his cell in the Segregation Unit. He had been
at Belmarsh for three days, having previously been at Highdown for four days.
He was charged with a serious offence, and it was his first time in prison.
2. The man had a history of harming himself and of depression and was
receiving treatment and medication in the community. He had spent time in a
psychiatric hospital.
3. Whilst at Highdown, the man made a ligature from a television wire. He told
staff this was not a serious attempt to take his life but a cry for help. This
prompted staff to initiate suicide and self harm prevention measures for the
man, known as Assessment, Care in Custody and Teamwork (ACCT).
4. After an appearance at court, the man was taken to Belmarsh prison. During
his time there he displayed disruptive and difficult behaviour which resulted in
him being located in the Segregation Unit. He was seen by a nurse who
assessed him as unfit to be detained there, so he was moved to healthcare.
However, he continued to behave disruptively in healthcare and it was
decided to move him back to the Segregation Unit. This time he was
assessed as fit enough to stay there. It was also during a review in the
Segregation Unit that the man’s observations were reduced from a constant
supervision to hourly checks. This report expresses concern both about the
decision to locate the man in the Segregation Unit and about the subsequent
reduction in observations.
5. The man’s medication and clinical care remained an issue throughout his time
at Belmarsh. He was prescribed medication which he did not appear to
receive and a mental health assessment was never carried out for him. Also,
a faxed solicitor’s letter detailing the family’s concerns about the man’s mental
health did not reach the appropriate department before he died.
6. I make nine recommendations. These include the decision to locate the man
in the Segregation Unit, suicide prevention procedures and observations,
clinical records and mental health assessments, correspondence, and first aid
equipment.
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THE INVESTIGATION PROCESS
7. Following notification of the man’s death, one of my investigators was
appointed to conduct the investigation. She visited HMP Belmarsh on
18 May, to open the investigation, meet members of the Senior Management
Team, visit the cell where he died and collect documentation. Notices were
issued to both prisoners and staff inviting anyone who had information
regarding his death to make themselves known to the investigator. No other
witnesses came forward.
8. My investigator visited Belmarsh on 22 June, 13 July, 18 August and 17
September to carry out recorded interviews with staff.
9. One of my family liaison officers wrote to the man’s mother on 22 June to
explain the role of the Ombudsman and to offer the opportunity to participate
in the investigation. The man’s mother contacted my family liaison officer at
the beginning of August and raised a number of concerns. These were:
- Why was the man on 15 minute observations at Highdown prison as he
had attempted to take his life there, but when he moved to Belmarsh
these were reduced to hourly observations?
- Who made the decision to reduce the observations, did they have the
authority to do so and why did they decide to do it?
- Why was the man alone in a cell with only hourly observations given
that he was unwell?
- Did the man receive his medication correctly?
- Why didn’t the man receive any of the mail or postal orders sent in to
him? Not being able to buy tobacco would seriously impact on his
ability to cope with imprisonment
- The man had been an in-patient at the Chiltern Hospital in July 2009
for mental health problems, as he had attempted to gas himself in his
car. His mother said she had made the police and prison staff aware of
this so that they knew his history.
10. I hope this report goes some way to explaining what happened to the man
whilst in prison and addresses the family’s concerns.
11. On 8 September, my family liaison officer forwarded a photocopy of all the
man’s prison records to his mother. A month later she wrote again to explain
the delay in issuing the report and that we were still awaiting a clinical review.
12. NHS Greenwich was commissioned to conduct the clinical review. The
clinical team comprised the Clinical Lead and Investigations Manager,
Independent General Practitioner and Medical Director at NHS Hillingdon and
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an Independent Investigator. This report was received in this office on 24
January 2011.
13. On 18 March, the man’s legal representative wrote to the Ombudsman. In
their letter they said that they had sent a fax to Belmarsh on 11 May
explaining their concerns and that of his family for his welfare, given the
attempt to take his own life the previous weekend (whilst at Highdown). They
did not receive a response from the prison and on 13 May were informed by
the man’s mother that he had died. The solicitors are concerned that the
contents of their letter were ignored by the prison and that the man was
located in a cell rather than in healthcare. They ask that their concerns are
considered as part of the investigation.
14. A letter apologising for the delay in producing this report was sent to the
Governor and the Coroner on 20 April 2011. No feedback was provided to
the Governor in person as he was unavailable, although feedback was given
to another member of the Governor’s senior management team.
15. A response to the report was received from Highdown and Belmarsh prisons
on 23 September. Highdown identified two factual errors. The first regarding
prisoners being permitted to smoke in their cells in healthcare. Also, the
Healthcare officer was mistakenly identified by a wrong name.
16. My investigator and another family liaison officer met with the man’s family on
2 November to discuss the draft report. The family agreed with the
recommendations made, but remained very concerned about the lack of
communication between the prisons, and the lack of postal orders and letters
he appeared to receive.
.
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HMP BELMARSH
17. HMP Belmarsh opened in 1991 and is a local prison, serving primarily the
Central Criminal Court and magistrate’s courts in South East London. In
addition, the prison serves Crown and magistrate’s courts in south west
Essex. Belmarsh has a dual role, in that it also holds category A prisoners.
There are four residential house blocks and a High Security Unit within the
prison.
HM Chief Inspector of Prison’s report (HMCIP)
18. The most recent inspection of Belmarsh by Her Majesty’s Chief Inspector
Prisons, was an unannounced full follow-up inspection in April 2009. In a
report published in December 2009, her comments included:
19. “Suicide and self harm prevention was taken seriously, and there was some
good work, but with a tendency to over medicalise the issue”.
Independent Monitoring Board (IMB)
20. Each prison has an Independent Monitoring Board (IMB) whose role it is to
monitor the prison and report any concerns about the way prisoners are
treated. Board members are able to visit any area of the prison at any time
and have direct access to any prisoner who they wish to see, or who requests
to see them. The IMB holds regular meetings in the prison, with the Governor
attending for part of the meeting. The Board produces an annual report that is
submitted to the Secretary of State for Justice.
21. With regard to Safer Custody, the IMB report for July 2008 until June 2009
says:
“There were 81 incidents of self-harm in the reporting year, 12 of which
involved foreign nationals.
“The most common form of self-harm remains cutting and scratching
which accounts for 56 of the acts. More than twice as many of the
incidents happened in the daytime rather than during the evening or at
night. There is some concern that occurrences are not being properly
recorded, particularly in Healthcare, but further guidance was given in
governor’s orders and it is hoped there will be an improvement.
“IMB members regularly carry out random checks on open ACCT
documents, and concerns were raised in the past that trigger points
were not being properly noted….and Care Maps (positive plans of
action) were inadequately outlined. There has been a notable
improvement in quality checking during the reporting year, not least
because of regular management checks. The Board intends to carry
out a more intensive and rigorous monitoring exercise in the near
future”.
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Critical Debrief
22. A critical debrief takes place after a serious incident. It gives the staff the
opportunity to understand the incident in greater detail, review their feelings
and normalise the reactions that some people experience after a traumatic
incident.
Cut down tools
23. Each officer and member of staff who is in contact with prisoners carries an
anti-ligature knife. These are knives which are specially designed to cut
through ligatures in a safe manner.
Reception and induction
24. A Cell Sharing Risk Assessment (CRSA) is opened by an officer in reception
who completes the basic details. The form is then passed to the First Night
Centre staff where a confidential interview is conducted. The document is
then passed to healthcare staff. The CSRA is intended to provide consistent
and continuing risk assessment regarding sharing cells.
Suicide and self harm monitoring
25. The Assessment, Care in Custody and Teamwork (ACCT) procedures aim to
support and monitor prisoners at risk of harming themselves. The Key aims
of ACCT are to create a safer environment, identify prisoners individual needs
and provide care and support before, during and after a period of crisis. Once
an ACCT is closed a post closure review should take place within seven days.
Other deaths at Belmarsh since May 2010
26. Since the man’s death there have been a further four self inflicted deaths at
Belmarsh. Two are still being investigated, whilst the other two do not have
recommendations which impact on the man’s death.
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KEY EVENTS
Highdown
27. On 6 May 2010, the man was remanded to HMP Highdown following a
hearing at Croydon Magistrate’s Court. He was due to attend the Central
Criminal Court on 10 May.
28. The man entered reception at Highdown and a first reception health screening
(a check made by a member of healthcare staff) was carried out. The
screening identified that the man had seen a doctor within the last few months
for depression and mental health issues. The man described the problem as
“schizophrenia and depression” and he said he had been an inpatient in
Chiltern and Sutton Hospital for two weeks in July 2009. The man also said
that he had a community care worker and was taking the medications
diazepam and fluoxetine (an anti-depressant).
29. The man also told the member of the healthcare staff that he had asthma and
an allergy to plasters. They discussed his alcohol consumption and he
described himself as a social drinker, consuming approximately two bottles of
spirits a week. The man was referred to see a doctor for substance misuse
and a mental health assessment, and was described as being very depressed
and low in mood.
30. Further medical history was taken by a member of healthcare staff at
Highdown. The man said that in the past he had tried to harm himself by
cutting and that he had also tried to gas himself in a car. Whilst an inpatient
at Chiltern and Sutton Hospital, a diagnosis had been made of paranoid
schizophrenia and that at the time of the alleged offence, he had been living
at a centre for people suffering from alcohol and drug abuse.
31. Later that day, the man saw prison Dr A. The doctor recorded that he had no
recollection of committing the offence for which he was charged, but the man
admitted to drinking heavily, sometimes two bottles of Jack Daniels a day.
The doctor confirmed that there were no signs of alcohol withdrawal and
prescribed a daily 20mg dose of fluoxetine and chlordiazepoxide (a sedative
for the short term treatment of severe anxiety which is also used for acute
alcohol withdrawal) when needed.
32. The man was admitted into healthcare from reception at 7.30pm because of
the seriousness of the charge. ACCT process were put in place to monitor
and support the man and, as part of these, it was agreed that he should be
located in a gated cell to enable him to be monitored closely on 15 minute
observations. (Prison Service Order (PSO) 2700 Suicide and Self Harm
Prevention prohibits the use of a gated cell for any prisoner who is not on
subject to constant supervision.) It was also recorded that chlordiazepoxide
(a drug for used for alcohol withdrawal) would be given to the man if needed
and that review would be held with him the next morning.
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33. The next day the man was described as being low in mood and
uncommunicative although he did accept his prescribed medication. Later
that evening he was noted as being tearful and spoke to a member of staff.
He requested a hug, which was refused, but he generally became more
settled.
34. On 8 May, it was recorded in the man’s medical notes that he was agitated
and crying a lot. He was seen by a doctor but the notes made following this
consultation are illegible.
35. The man had been in a highly emotional state and told staff that he could not
cope and should not be in prison. He also requested diazepam (it is not clear
from the documentation supplied whether he was given this). The staff
starting their afternoon shift were alerted to the man using a television wire as
a ligature. He was lying in the corner of the gated cell (although not on
constant watch) with the ariel around his neck attached to the hand rail by the
toilet. He was also crying uncontrollably. The man’s breathing was not
affected. An immediate action plan (part of the ACCT process) was started by
Senior Officer (SO) A. The plan was to allocate the man to a safer cell in
healthcare, implement 15 minute observations, ensure that staff had three
meaningful conversations with him a day, that he was observed hourly at
night and given access to the Samaritans telephone. It is also recorded that
the man had a visit that day, from 2.00pm until 3.55pm approximately, with his
family.
36. Later that evening the man repeatedly requested tobacco. It was decided that
his behaviour meant that he should have a full mental health assessment and
a referral was made.
37. The next day SO A carried out an Assessment, Care in Custody and
Teamwork (ACCT) review, following the man’s attempt to harm himself the
day before. The man told the SO that he had felt distressed because of his
withdrawal from smoking, that he had no more money to buy any tobacco and
he had smoked his smoker’s induction pack. The man added that this was
not a serious attempt to harm himself, but more a cry for help related to his
withdrawal from tobacco. The Healthcare officer also noted at the ACCT
meeting that the man seemed frail and vulnerable and was seeking sympathy.
38. It was also noted that the man said he had attempted to harm himself
previously, by gassing, cutting and poisoning himself. He attributed this to not
having had the “most happy of lives” due to family deaths and other issues
which he did not elaborate on. The man told staff that he was feeling better
and wanted to think about leaving healthcare and re-joining the main prison.
He was told about coping resources available to him within the prison and a
mental health assessment was requested. The next ACCT review was
scheduled for 16 May.
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Belmarsh
10- 11 May
39. On 10 May the man attended the Central Criminal Court and as a result was
transferred to Belmarsh prison from there. Whilst in reception, he underwent
a Cell Sharing Risk Assessment. It was noted by the member of staff who
completed the assessment that he was a smoker and that he would have to
share a cell as he was on an open ACCT (although this is not necessarily
required under the guidance in PSO 2700 ). A note was added to say that the
man was on an ACCT (which had travelled to Belmarsh with him) but that he
was not suicidal, and appeared to be well.
40. An Induction Passport (which holds details of the man’s induction into the
prison and outlines the rules and responsibilities of a prisoner at Belmarsh)
about his immediate needs was also completed. It determined that this was
his first time in custody, aside from the four days he spent at Highdown, and
confirmed that he had been issued with an induction booklet, a comfort pack
(which contains essential items such as a smokers pack supplying him with a
quantity of tobacco, teabags, coffee and so on) a meal and a drink. He had
also been allowed to make a telephone call, and had been seen by a member
of the Detox Team.
41. During this induction meeting, the man was asked whether he considered
himself to be vulnerable, and he said he did not. He had no concerns at that
stage about sharing a cell on the First Night Centre and although he said that
he had attempted to harm himself in the past, he did not feel suicidal at that
time. The man said that he did not have any drug or alcohol issues and did
not require any support in this area.
42. The man was seen by staff nurse A at 18.26pm on 10 May, who recorded
details relating to his address, offence and other general matters. A short
while later, he was seen by Nurse B. During her interview with the
investigator, she said the purpose of the meeting was to ‘register’ the man
and discuss any issues he might have. She recorded in the medical records
after speaking to the man that he said that he did not feel suicidal, that there
were no concerns about his mental health, but that he had received treatment
in a psychiatric hospital in the community in the past. A previous note in the
medical records indicated that he had tried to harm himself previously and
had received medication for mental health problems. In particular it was
noted that he had attempted to hang himself two days earlier whilst he was at
Highdown prison. The man said he used cannabis but said he suffered from
no health problems apart from occasional chest pains.
43. The man told Nurse B that he had received Fluoxetine 20mg (an anti-
depressant) and Diazepam 5 mg (for anxiety) in the community and was also
prescribed this medication at Highdown. It was acknowledged that he was on
an open ACCT and was at risk of harming himself.
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44. At 20.45pm, prison Dr B saw the man for a further assessment in the First
Night Centre. The doctor recorded in the medical notes that the man had a
history of schizophrenia and anxiety and that he told her he was taking
Fluoxetine 20mg and Diazepam. She noted that he appeared well and not
suicidal. The doctor referred him for an assessment by the mental health
team and prescribed him 15 Fluoxetine 20mg tablets, one to be taken every
morning, and two Diazepam 5mg tablets, one to be taken of an evening for
two nights. This medication was to be administered to him by healthcare
staff.
45. There is some discrepancy regarding the man’s prescription and medication.
The electronic medical records say that prison Dr B saw him on the evening of
the 10 May and the medication was prescribed from them. However, there
was also a paper prescription chart which suggests that the doctor saw the
man on the 11 May, that he only took the Diazepam on the evening of the 11
May and did not take his medication on the 12 May. The paper prescription
chart also shows that he was prescribed Fluoxetine on 10 May and took it on
the mornings of 11 and 12 May. There is no record of either of these drugs
being administered on the electronic records system. At interview, the Head
of Healthcare agreed that the two records were recording different and
conflicting information, but was unable to explain this further, although the
confusion might have been due to the new electronic system that staff were
getting used to using.
46. After the interviews with induction and medical staff, the man was sent to a
shared cell in the First Night Centre, where it was recorded that he slept well
overnight.
47. The next day, 11 May, the man was seen by Staff Nurse C. She noted that
he had been diagnosed with schizophrenia and had been admitted to Jasper
ward (a mental health ward) in the Sutton and Chiltern hospital several times
in the past. There are also some entries which contradict the information
collected the previous evening as on this occasion the man did not say he
suffered from chest pain or say that he had asthma. (An entry made on the
electronic medical records system on 14 May states that the nurse made a
paper referral to the mental health team on 11 May at 12.30pm, which was
handed to the team in time for their 1.00pm meeting that day). It is unclear
whether this was an urgent or routine referral.
48. A Cell Sharing Risk Review was also carried out for the man on 11 May. It
determined that he remained a low risk to other prisoners and could share a
cell. A note made by the same officer (signature illegible) in the Wing
Observation Book says that he had no thoughts of harming himself and that
he was aware of the support that was on offer. It was recorded in the book
that he was on an open ACCT but he said he felt “fine”. He had been given
all of the induction booklets and leaflets and had signed to acknowledge
these, and had had all prison compacts (agreements between the prisoner
and prison) regarding behavioural standards explained to him.
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49. At 13.36pm a letter from the man’s solicitors was faxed to the Governor’s
office. The letter explained the concerns that the man’s family had about his
welfare. These were that he had depression and anxiety and had been
diagnosed with paranoid schizophrenia and that he had made many suicide
attempts previously, most recently on 8 May whilst at Highdown. The man’s
mother was concerned that he had not been receiving his medication of
Fluoxetine and Diazepam for a week prior to his arrest on 5 May. She
believed that he should be located in healthcare and that he should be seen
by a psychiatrist.
50. During a visit to Belmarsh, my investigator spoke to Nurse D about the letter.
The nurse explained that the faxed letter was received in the Performance
Management Unit (PMU) on 12 May. This is located in an office in the main
administration block. PMU scanned the letter and sent it via e-mail to the n
nurse on the afternoon of 12 May. The nurse did not see the e-mail until the
afternoon of 13 May but then took it to the Head of Healthcare. Unfortunately,
the man was already dead by this time. It is not clear what happened to the
fax between its arrival in the early afternoon of 11 May and its receipt into
PMU on the morning of 12 May.
51. An ACCT review was held at 3.00pm the same day. Two senior officers
attended the meeting with the man. It was noted that the review was brought
forward as the man did not return to Highdown prison. The man seemed
quite nervous and agitated during the meeting and said that his attempt to
take his life three days earlier had been a serious one, although he was
pleased that he had been found in time and did not die as it had made him
realise how much his family meant to him. It was agreed that the ACCT
should remain open and a review was to take place on 18 May. The
frequency of observations remained as agreed at Highdown.
12 May
52. The next day the man was unlocked for breakfast and after eating attended
exercise. He asked a member of staff about the money he had available in
his prison account and was told somebody would look into this for him. It
seems that a postal order would take ten days to clear into a prisoner’s
account, so effectively a prisoner could be without money for two weeks. He
had no other issues. That afternoon he attended day two of the induction
programme and appeared quiet and polite. He collected his lunch and said
he was “fine” and looking forward to attending the gym induction later that
day.
53. Some time later, the duty governor for the day, received a message to say
that a prisoner (the man) had “smashed up” his cell on the First Night
Induction Centre. The man had been in the cell on his own when he did this.
The duty governor agreed that the man should be escorted to the Segregation
Unit and asked that he be informed when the man arrived there. At this stage
he was not aware that the man was on an ACCT. He said during his interview
that it was normal practise to place a prisoner in the Segregation Unit
because of his behaviour, pending adjudication.
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54. After the man was located in the Segregation Unit a segregation safety
algorithm was carried out by a member of the mental health team. (This is an
assessment tool used to establish whether it is appropriate for a prisoner to
be held in the Segregation Unit). The member of the mental health team
concluded that the man was not to be located in the Segregation Unit as
although he was not showing signs of acute mental illness, he appeared
“impulsively suicidal”. This note is made in the on-going record of the ACCT
form, but not in the man’s medical records.
55. The duty governor for the day was told of the member of the mental health
team’s assessment and it had been decided to take the man to healthcare.
The man was admitted to Ward One and arrangements were made for him to
be seen by a psychiatrist the next day. Ward One is a dormitory style unit,
with six beds in it. The man was located there as there were no single cells
available in healthcare.
56. At 4.10pm an ACCT case review was held in healthcare. It was noted that the
review was as a result of recent events and the man’s admittance to
healthcare. The man said at the meeting that he felt frustrated that his money
had not been transferred from Highdown and that he did not have any
tobacco. He said he did not have any thoughts or plans to harm himself and
did not feel he needed to be in healthcare, but was happy to remain there until
he was reviewed. There is no entry in the ACCT to explain what plans were
made to alleviate these problems, but a review date was set for 18 May.
57. Less than an hour later it was reported that the man began to create a
disturbance in Ward One. He was banging his fist on the wall and shouting.
Nurse E, who was working in healthcare, went to see what was happening.
The man said that Nurse E should get him out of Ward One before he
“smashed up the place”. He was becoming very aggressive and said he
would “kill someone” if he remained there. The nurse called for assistance
and two officers came out from the day room to help. They opened the ward
door, asked the man to stand in the corridor and tried to calm him down. The
nurse began talking to him, but the man remained angry and demanding. He
said that he did not want to be in healthcare, that it was not the place for him,
that he was not mentally unwell and he just wanted a cigarette (smoking is not
permitted in healthcare). He said that if he returned to Ward One he would
“kill someone”. The nurse could not identify anyone to move from a single cell
to accommodate the man, so called for the duty governor of the day for his
advice and assistance.
58. Nurse E said that at this point, the man’s actions were strictly ‘behavioural’,
meaning that they had had nothing to do with a mental illness, and therefore
presented a control problem. When asked about this at interview, the nurse
told the investigator that in his opinion the man was fully aware of the threats
he was making and what he was doing and that, in his view, it would not be
safe for him to return to the ward.
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59. The duty governor of the day arrived in healthcare and saw the man who was
standing in the corridor with a number of staff members. The governor tried to
speak to him to ascertain what his issues were. (He had been told a short
time earlier that the man had watched a television programme about
Wormwood Scrubs and had seen a prisoner there say that if you “kick off” you
can get anything you want.) The governor asked the man what was troubling
him and he replied that he had no tobacco and wanted to smoke. The
governor established that the man had already had two smoker’s packs given
to him which contained a pouch of tobacco, Rizla papers and means of
lighting the cigarette. The pack is supposed to last a prisoner a week, or until
they have their own money to purchase goods from the prison canteen. At
that stage the governor was not aware of how important smoking was to the
man and had not seen the man’s ACCT (which said that not being able to
smoke was a trigger for self harm for him).
60. The duty governor of the day tried to explain to the man that his behaviour
earlier that day had meant he should be located in the Segregation Unit, but
as it was deemed unsuitable to stay there, he had been moved to healthcare
where he could only smoke during outside exercise. The man became very
angry and said that the governor was “winding him up”. The man then
jumped up and moved towards the duty governor and was restrained by staff.
He put up a struggle, but was eventually placed in handcuffs. The governor
said he believed the man was about to assault him.
61. The duty governor of the day said at this stage he was aware that there were
no single cells available in healthcare and the man could not return to the
ward environment. As he realised that the man would not be able to smoke in
healthcare, but that he would be able to in the Segregation Unit, he thought
that as part of a de-escalation attempt, the man should return there. The
governor said he was aware that the nurse had assessed the man as
unsuitable for the segregation unit.
62. They duty governor of the day completed a form ‘Exceptional circumstances
for the continued segregation of a prisoner on an open ACCT’. This form is
used to explain why it is necessary for a prisoner to be located in the
Segregation Unit, despite being subject to the ACCT process. He wrote:
“The man was removed from HB3 earlier today due to smashing his
cell. He stated the reason for this was due to the fact that he had no
tobacco. The man has been given two smokers packs since he arrived
at Belmarsh but has used them up in a short period and now has no
money to buy anymore. He was taken to the Segregation Unit due to
his refractory behaviour but then moved to a ward on the HCC due to
failing the initial segregation health screen. At approximately 17.10
hours a call was received in the Orderly Office stating that the man was
smashing himself against the ward cell door. He was immediately
removed from the ward to protect the other inpatients, however there
was no unoccupied single cell in the HCC to accommodate him. The
duty governor attended the HCC to speak with the man, however
during his conversation with him the man attempted to assault the duty
15
governor and was restrained. Due to continued refractory behaviour it
became necessary to locate the man in a cell in the Seg Unit. The
man is currently on an open ACCT document (opened 9//5/10). His
only trigger which is listed is “no tobacco”. It was decided that to keep
the man safe, he would be placed in a gated cell in the Seg Unit and
under constant supervision. A small smoker’s pack has been obtained
and the man allowed to smoke but only at the discretion of the Seg PO
– he is not to remain in possession of the tobacco as he will likely
smoke it in a few days. It has to be a consideration that, whilst not
desirable to hold him in the Segregation Unit on an open ACCT, he is
able to smoke in the Seg Unit and not the HCC.”
63. At 6.00pm Nurse F carried out a second algorithm to ascertain the man’s
suitability to be located in the Segregation Unit. The nurse acknowledged that
the man had a history of harming himself and required frequent observation.
However, this time the man was thought to be suitable to remain in the
Segregation Unit. The duty governor for the day counter signed the form and
confirmed that the man should be located in the Segregation Unit for
operational reasons and that a case review was needed immediately. The
man was placed in a gated cell which allowed constant supervision by staff,
meaning a member of staff would sit outside the cell and watch him
continually. They would also make a note in the Observation Book every 15
minutes.
64. During his interview with the investigator, the head of healthcare said that
aside from the single cells, there was also a gated cell in healthcare which
although occupied at the time may have been an option. Also, there were two
gated cells in a contingency suite. He said he would have considered all of
these options before moving the man to the Segregation Unit.
65. The Senior Officer (SO) in charge of the Segregation Unit when the man
arrived there the first time that day. He recalled that there was no force
involved when the man was escorted there and that he failed the algorithm
completed by the member of the mental health team. The SO told the
investigator that it is rare for a prisoner on an open ACCT to be located in the
Segregation Unit, but it does happen.
66. Following his return to the Segregation Unit, the SO in charge of the
Segregation Unit that day carried out the constant supervision of the man for
the first two and a half hours. The man did not talk about anything significant,
and the tobacco arrangement was that he could request it from staff when he
needed to. The SO was relieved by Officer B at 8.35pm. He was fully briefed
by the SO and introduced himself to the man. The man told Officer B that he
was “ok” and showed no signs of self harm. Throughout the night, nothing of
note was recorded and the man appeared to sleep on and off until the next
morning.
16
The day the man died
67. The man ate breakfast at 8.30am and spent the rest of the morning laying on
his bed, reading and smoking. When SO in charge of the Segregation Unit
arrived back on duty he was told that the man had been fine overnight.
68. However, at 10.35am the man put toothpaste all over his head and face,
which he then mixed with soap. As a result he was given a full body search
and taken to the shower to clean up. He then returned to the gated cell and
constant supervision was resumed.
69. At 11.50am an ACCT case review was attended by the man, the SO in charge
of the Segregation, the member of the mental health team and two other
officers. The man said that it was access to tobacco which affects his
behaviour and it is the only way he can reduce the stress of being in prison.
He told the review that he had no thoughts of harming himself or of suicide. It
was noted that the man showed good insight into his current situation and
was able to explain what plans he had for the future. These centred on a
return to work as a scaffolder and “becoming a reformed character” and
indicated that the man was thinking about his future. The man also
apologised to the SO for his behaviour the previous day. The member of the
mental health team said he was happy to provide mental health support and
monitoring on a weekly basis, but said at interview that he was not aware at
this stage that the man had still not been assessed by a psychiatrist, as this
would normally happen before a prisoner is discharged from healthcare. The
member of the mental health team said that if he had known that an
assessment had not taken place he would have re-referred him.
70. All those present at the review believed that it was safe and appropriate to
move the man from the gated cell to a normal cell in the Segregation Unit and
it was agreed that observations could be reduced to an hourly watch. The
man remained in the Segregation Unit because the issue of smashing his cell
and the attempted assault on the duty governor were still outstanding and
also because he was permitted to smoke there, which remained extremely
important to him.
71. SO in charge of the Segretion Unit told my investigator that the man was
moved to a normal cell in the Segregation Unit at approximately 12.15pm.
The SO spoke to him about 15 minutes later and gave him a cigarette. The
man appeared calm and relaxed. Staff on the Segregation Unit continued
serving lunch to all the prisoners and then completed their paperwork for the
morning.
72. An Officer C was covering lunch duty that day. When he arrived for duty that
morning he had seen that the man had be located in the gated cell, but did not
know any further information about him. Up until lunch time, Officer C had
been completing paperwork in the wing office. The officer recalled that the
SO in charge of the Segregation Unit had put the ACCT document for the
man on the desk in the office and told the officer that he had rolled him some
17
cigarettes, had a chat with him and that he seemed okay, and “should be
alright through lunch”.
73. At around 12.45pm the SO recalled that the officer offered to make some
drinks and said he would carry out cell observations on the way. The officer
explained that the observations were not particularly his responsibility, but as
he was making drinks, he had offered, and he knew that the man was due to
be checked.
74. When Officer C looked into the man’s cell through the observation panel, he
noticed he was looking out of the window. They did not speak at all. The
officer did not record this observation in the ACCT and said during his
interview that this had been a mistake on his part.
75. From about 1.30pm the SO in charge of the Segregation Unit and four other
staff were dealing with a prisoner in the Segregation Unit who required a
senior officer and four officers unlock (the minimum number of staff needed to
unlock this prisoner). They dealt with this prisoner’s applications, exercise
and shower and a cell clean. The cell clean required staff to dress in
protective clothing. Whilst attending to this prisoner the staff were also
dealing with other prisoners applications and requests.
76. At 1.45pm the SO returned to the wing office to attend to some paperwork for
the Segregation Unit prisoners weekly review. A member of the Independent
Monitoring Board (IMB) (who was attending the reviews) and Nurse G were
also in the office.
77. At this time another officer, Officer D, escorted a prisoner to use the telephone
just outside of the man’s cell. Officer D said at interview that he had a feeling
he needed to check on the man, and looked through the observation panel.
The officer said that he saw the man at the window in a seated position, with a
ligature (a jumper) around his neck and tied to the bars of the window.
78. Officer D immediately called to a colleague, Officer E, to ask for assistance
and he then entered the cell. He was closely followed by Officer E and the
SO in charge of the Segregation unit, who had heard her call for assistance.
The SO shouted to Officer C to raise the alarm bell. Officer D recalled that
the man appeared almost blue in colour and his mouth was open.
79. Officer D tried to untie the ligature but it was not possible to do so because of
the way it had been tied. The SO and Officer E then lifted the man slightly to
take the pressure off of him, and Officer D used an anti-ligature knife (a knife
with a specially designed blade to cut through ligatures) to cut through the
jumper. As it was so thick, Officer D could only cut a bit at a time which he
estimated took two or three minutes. During this time, Officer E was trying to
get a response from the man. Once the ligature had been released the three
members of staff laid the man onto the floor of the cell. Officer D checked for
a pulse in the man’s neck, but found none. (Officer D was a first aider with a
current qualification.) He therefore began administering chest compressions
immediately.
18
80. Despite being a first-aider, Officer D had not been issued with any equipment,
so Officer C ran to get a mask to use whilst administering mouth to mouth
resuscitation. Officers D and C worked at the ration of two breaths to 30
compressions, however they were struggling to get air into the man.
81. At some point an ambulance was called, although the exact time is unclear,
as is who made the call. The SO believed it was the Orderly Officer (Oscar
One) and Nurse G could not remember who called the ambulance.
82. Nurse G arrived back at the cell after having left to ring healthcare to request
an emergency response from the wing office. She was not carrying a radio
that day and so had to use the telephone in the Segregation Unit office. At
some point Officers D and C swapped roles and Nurse G continued to monitor
the man’s pulse.
83. The SO realised the cell was beginning to become cramped and decided to
leave there to manage the rest of the Segregation Unit. He briefed staff from
healthcare and security as they arrived. A member of healthcare, Nurse H
arrived with an emergency bag, but not a defibrillator. (A defibrillator is a
machine which detects whether there is a detectable heart rhythm which can
be shocked into starting again.) As there was not a defibrillator in the
Segregation Unit at that time, a member of staff ran to healthcare, which is
located very close by. However, Officer D said that they had difficulty finding
a defibrillator and it took around 15 minutes to locate one.
84. Whilst waiting for the defibrillator and the ambulance, Officers D and C
continued with resuscitation, assisted by nurses G and H. Once the
defibrillator arrived Officer D applied the pads to the man and pressed the
start button. The machine indicated that no shock was advised, which meant
it was not detecting any heart rhythm. Officer D said the defibrillator works in
three minute cycles and recalled that he used the machine at least three times
before the paramedics arrived. Each time no shock was advised.
85. The reverend and Governor A were in the prison at the time. They were
together when they were told that there was an incident in the Segregation
Unit and made their way over there.
86. The reverend recalled at interview that he saw the man and from his
experience, thought he could not be revived. However, he understood that
staff had to continue with their resuscitation attempts until paramedics arrived.
The reverend realised he could not be of any assistance, so began to talk to
the staff who had moved away from the man’s cell and may have been in
need of some support. He then collected the man’s next of kin information
and records. The reverend identified the man’s mother and her address.
87. Staff continued with resuscitation attempts until the paramedics arrived. Their
entry into the prison was quick and unhindered and they arrived in the
Segregation Unit at approximately 2.10pm.
19
88. The paramedics asked that the man be lifted out onto the landing to give them
more room to attend to him. Officer D and one paramedic did so. However,
their resuscitation efforts were unsuccessful and the man was pronounced
dead at 2.30pm. He was moved back into the cell and placed on the bed.
Once the police had attended the prison, the man was taken to the mortuary.
89. Only one other prisoner in the Segregation Unit was on an ACCT and this was
reviewed immediately, and all other prisoners in the unit were checked and
offered the services of a Listener (a prisoner who has been trained by the
Samaritans to offer confidential support in times of crisis) or the Samaritans.
90. A debrief was arranged by Governor A, for all staff involved with the man’s
death at approximately 3.15pm. Staff from the Care Team and managers
checked on the well being of staff, and my investigator found that staff
generally felt well supported. Staff were offered the opportunity to go home,
but they all elected to remain and finished their shift. The Segregation staff
then carried out their own informal debrief at the end of the shift to talk over
what had happened and offer support to each other. (A critical incident
debrief was also held some time after the man had died, but no record was
kept and staff could not remember the date this was held.)
91. At approximately 5.00pm the reverend and Governor A left the prison to visit
the man’s mother. They had spent some time checking records and ensuring
they had the correct name and address. They arrived at the address around
an hour later. They knocked on the door but received no reply. They
returned to the car and drove a little way away from the house, so they were
not sitting directly outside, and decided to wait. The man’s mother had been
in when the reverend and the governor had knocked, but was reluctant to
answer the door. She rang a neighbour who went to see them and asked
what they wanted. The reverend said that he was unable to go into detail, but
explained that they were from the prison. The neighbour proceeded to escort
them to the house.
92. The man’s mother had opened the front door, and was already very
distressed. The reverend said that the man’s mother had guessed what the
news was as soon as she knew they were from the prison, and they hardly
had the opportunity to relay any information before she left the room.
93. The man’s uncle arrived (it is not clear whether he was telephoned) and the
reverend spent some time explaining what had happened. The governor
remained with the man’s mother until she re-entered the room. The reverend
explained that the prison would contribute to funeral expenses and offered to
conduct the service, and said that they could visit the man’s cell if they wished
to do so. They stayed some time, and ensured the family had all of their
contact details before they left.
94. A few days later the reverend took the man’s belongings to his mother. It
appeared that some items were missing that the prison were unable to trace.
Two days later the reverend met the family at the mortuary to see the man.
He then accompanied them to the prison, where they visited the Segregation
20
Unit and said some prayers. The reverend gave them some letters and postal
orders that had arrived at the prison for the man. The next weekend the
reverend visited the family to discuss the man’s funeral arrangements, which
he conducted the following week on 27 May. The reverend then interned the
man’s ashes at his father’s grave on 7 June.
95. The reverend told my investigator of the family’s concerns. The man’s mother
said she felt that her son had been let down by the whole system, including
the mental health system. She was also concerned that both Highdown and
Belmarsh were aware of the risks that the man might harm himself and
questioned whether this information was passed from one prison to the other.
She was unable to understand how the man had been able to take his life
whilst being on an ACCT and did not understand why he had not been located
in healthcare. She was also concerned about whether the man had received
his medication and whether he was taking it whilst at Belmarsh.
21
ISSUES
Information passed from Highdown to Belmarsh
96. Highdown alerted Belmarsh to the man being a prisoner at risk of harming
himself again, and was on an open ACCT. Belmarsh received all the relevant
documentation when receiving the man, and immediately explored his health
issues in reception. The man also had an ACCT review at Belmarsh the next
day.
The man’s location in the Segregation Unit at HMP Belmarsh
97. The man was initially located in a ward in healthcare, awaiting a mental health
assessment after smashing up his cell in the First Night Centre. He shared
the ward with a number of other prisoners, some of which were elderly (one
prisoner was 95 years old) and very unwell. The man became agitated and
aggressive and said he did not need to be in healthcare and would “kill
someone” if he remained there. He was also very upset because smoking is
not permitted anywhere in healthcare. He did not calm down when the duty
governor came to speak to him and the duty governor believed that the man
attempted to assault him. Despite not being deemed suitable for location in
the Segregation Unit earlier that day (after failing the algorithm), he decided
that the man should be moved to the Segregation Unit and another algorithm
carried out for him.
98. There are single cells in healthcare but these were all occupied at the time.
However, the Head of Healthcare said that there is also a gated cell in
healthcare and two further gated cells in a contingency suite. He said he
would have considered all of these options, and moving other prisoners
around, before moving the man to the Segregation Unit. I think that more
thought should have been given at that stage to assessing the risks and
possibility of moving some prisoners, to find an alternative location for the
man. This is especially important given the algorithm assessment made
earlier which found the man unsuitable to be located in the Segregation Unit.
However, it is important to note that he still would not have been allowed to
smoke in the other locations that may have been more suitable for him and it
is clear that to be able to do so was vital to him. It is also important to
acknowledge that the man was still displaying threatening behaviour and the
safety of staff and other prisoners was also a deciding factor in where to place
him.
99. The duty governor made a judgement about moving the man to the
Segregation Unit and spent some time completing a form to explain why a
prisoner on an ACCT was being located in the Segregation Unit. He also
arranged for the man to be allowed tobacco. It was also agreed that the man
should be given 24 hour observation in a gated cell. The decision to place the
man in Segregation is questionable, and I consider that the other options
should have been exhausted before this step was taken.
22
Prison Service Order 2700 says that prisoners on an open ACCT should only
remain in the Segregation Unit in exceptional circumstances, whereby they are
such a risk to others or no other location is appropriate. I accept that the
man’s behaviour was exacerbated by his lack of tobacco and not being able to
smoke in healthcare, but I still believe that the possibility of moving other
prisoners around to accommodate him in a single or gated cell in healthcare
would have been a sensible option. I am not convinced that enough thought
was given to this option. However, I also accept that whilst he was in the
Segregation Unit he was treated with care and staff were alert and attentive to
his needs.
The Governor and Head of Healthcare should ensure that all options are
thoroughly explored by staff before a prisoner is moved from healthcare
to the Segregation Unit, especially if they have failed the algorithm a few
hours earlier.
Reduced observations
100. At the ACCT review on the morning of 13 May, all the staff present agreed
that the man should be moved from the gated cell and observations should be
reduced from a constant supervision to hourly checks. This is despite his odd
behaviour earlier that morning when he covered his head and face in a
mixture of toothpaste and soap. Staff said he presented himself well at the
review meeting and said he had said that he had no thoughts of harming
himself. Prison Service Order 2700 describes constant supervision as a
temporary arrangement designed for prisoners in “acute suicidal crisis”.
However, I am surprised that the risk to the man appeared to diminish so
quickly that his observations were reduced from constant to hourly with no
stages in between.
101. Prison Service Order 2700 also says that prisoners charged with murder are a
particularly high risk group and given that this was the man’s first time in
prison and he was clearly suffering with mental health issues, more care and
consideration should have been given to reducing the observations so
drastically.
Failure to carry out a mental health assessment
102. Despite the member of the mental health team attending the ACCT review
meeting, there does not appear to have been a full and thorough assessment
of the man’s mental state at any stage. In fact, the member of the mental
health team was not even aware that the man had not yet had a mental health
assessment. I would have expected to see a record of a more searching and
robust meeting, considering the man’s behaviour. There is no explanation in
the paperwork to explain why the assessment did not take place and why the
member of the mental health team was unaware of this before he attended
the review.
23
The Head of Healthcare should ensure that there are failsafe processes
in place for referrals and follow through in a timely fashion.
103. I also question the voracity with which the man was asked about his
intentions. I remain convinced that hourly observations were not adequate for
a person who had just been removed from constant supervision and I bring
this to the attention of the Governor for his consideration.
104. The clinical review recommends that a review of the ACCT panel
membership, further training and random audits are carried out. It goes on to
say that clarification is needed for the role of (particularly) healthcare staff and
the importance of their specialist knowledge and experience. The reviewer
also comments that all ACCT review members should be aware of the
individual’s full history and their previous ACCT documents. I endorse this
recommendation.
The Governor and Head of Healthcare should ensure that staff carrying
out an ACCT review are adequately trained, and should be fully aware of
the prisoner’s history. In particular, healthcare professionals should be
aware of the importance of their specialist knowledge and
responsibilities in this area (for example, mental health referrals).
Medication
105. The man’s family were concerned that he was not receiving the correct
medication. He was prescribed Fluoxetine and Diazepam in the community
and at Highdown and this was also prescribed at Belmarsh on the evening on
10 May. There appeared to be an electronic record of the prescription on 10
May and also a paper record. It was the paper record which recorded that the
man was given Diazepam on the evening of the 11 May and Fluoxetine on the
morning of 11 and 12 May. This was not recorded electronically on the
healthcare system and it is unclear whether prison Dr B had access to the
electronic record and the clinical review makes a recommendation in this
regard. There was no record anywhere to indicate that the man received any
medication on the 10 May.
The Head of Healthcare should ensure that clinical records are available
to clinicians or that the clinician has access to the electronic system
before reviewing a prisoner.
106. Also, the paper prescription record indicates that the man was prescribed
Diazepam for two days, but Fluoxetine for 28 days. However, there is a line
drawn after the Fluoxetine dose administered on 12 May (which the head of
healthcare said usually indicated that the medication was to be discontinued),
and the man did not receive any the next morning. The head of healthcare
was unable to explain this (and prison Dr B was unavailable for interview as
she no longer works at the prison).
107. Further, there is no record to show whether the man took the second
Diazepam tablet, as only the one given to him on 11 May is noted.
24
108. The prescription records are misleading and confusing. None of the decisions
or actions are explained and nobody is able to clarify when the man received
his medication. This is clearly unacceptable. The clinical reviewer also
comments on the need for effective record keeping in line with General
Medical Council guidance.
The Governor and the Head of Healthcare should undertake a review of
medical record keeping within the prison and ensure that processes are
introduced to maintain records in line with General Medical Council
guidelines
Recording observations
109. While I am aware that Officer C did carry out a check on the man at
approximately 12.45pm that day, he did not record it in the ACCT. I
understand that Officer C was very busy, but the importance of recording
ACCT checks can not be understated and staff should be reminded of this.
The Governor should remind all staff of the importance of following
ACCT guidelines and of recording all prisoner observations in the ACCT
documentation.
The faxed letter from the man’s Solicitor
110. I find it unacceptable that the letter sent by the solicitors, regarding the man
and his family’s concern about his mental health, medication and general well
being, was not acted upon with more urgency. It is surprising that the person
who scanned the letter onto the e-mail system and forwarded it to Nurse D,
did not read or note the serious nature of the contents. The failure to alert
anyone to the letter, and purely to rely on it being routinely opened at some
stage meant that nobody in healthcare saw it until after the man had died. I
would suggest that the system of forwarding important correspondence and
faxed documents is reviewed as a matter of urgency, so that staff are alerted
to potential problems immediately. This recommendation is also made by the
clinical reviewer.
The Governor should review the system for passing correspondence
around the prison, to ensure that important documents are seen as a
matter of urgency.
Defibrillator
111. There is no defibrillator in the Segregation Unit and staff had difficulty locating
one in healthcare. This took around 15 minutes, which is unacceptable. It is
not possible to say whether prompt access to the defibrillator would have
made a difference to the man’s condition at that stage. However, it is
obviously of great concern that a key piece of emergency equipment could not
be quickly and easily located. Staff must be told where all the defibrillators in
the prison are situated and be able to gain access to them without delay.
25
The Governor and Head of Healthcare should ensure that all staff are
told where defibrillators are situated around the prison, and are able to
gain access to them in an emergency.
First aid equipment
112. Despite being a qualified first-aider, Officer D had not been issued with any
appropriate equipment, and asked another officer to find a mask for him to
enable him to administer mouth to mouth.
The Governor and Head of Healthcare should ensure that all qualified
first aiders are issued with appropriate equipment.
Receiving postal orders and money for canteen
113. As the man had been at Belmarsh for such a short time it would have taken a
while for him to receive any money. This is a service-wide issue and not
particular to Belmarsh, it takes a few days to transfer the information from one
prison to another. However, he was issued with smoker’s packs and other
essential items until funds became available. He was also given tobacco
whilst he was in the Segregation Unit. This is usual practice in prisons.
26
CONCLUSION
114. This had been the man’s first time in prison, and he was charged with a very
serious offence. He also entered custody with serious mental health issues,
for which he had been receiving treatment and medication. He had attempted
to harm himself on a number of occasions while in the community.
115. His behaviour at Highdown gave cause for great concern and as well as
receiving appropriate medication he was reviewed in healthcare on a 15
minute observations (prior to being placed on an ACCT) and then monitored
under ACCT procedures immediately after he attempted to harm himself. His
behaviour at court on 10 May was also worrying. This information was
passed from Highdown to Belmarsh within the documentation that travelled
with the man.
116. The man went through the appropriate induction procedures when he arrived
at Belmarsh, and these were carried out well. However, his medical
assessment, the clinical notes and the medication which he was prescribed
are confusing and unclear. It does not seem that he was given more than one
Diazepam tablet during his time there and for some unknown reason it
appears that his prescription for Fluoxetine was discontinued. It is also
worrying that a faxed solicitor’s letter outlining their concerns about the man’s
mental health and need for medication did not reach the correct person until
after he had died.
117. There is no doubt that the man was a very challenging prisoner for staff to
deal with. He was somewhat obsessive about his need for tobacco and being
allowed to smoke and this appeared to be an important trigger for his difficult
behaviour.
118. He was quite rightly transferred to healthcare for assessment after smashing
the contents of his cell on the First Night Centre, but given his unpredictable
nature, perhaps more thought should have been given to where he was
located in healthcare. I do not believe that staff had no other options available
to them and could not move some prisoners around to accommodate the man
in a more appropriate environment than the Segregation Unit. I question the
decision to return him there so soon after he had failed the algorithm.
However, I do understand that the issue with tobacco, and not being permitted
to smoke in healthcare would have remained and would have needed to be
managed carefully.
119. It is also of concern that the man seemed to slip through the net, and that his
mental health assessment was not carried out, despite a referral. It is also
worrying that mental health staff were unaware that the review did not take
place. This is especially important given his behaviour during his time at
Belmarsh, and in healthcare and the Segregation Unit in particular.
120. The decision to reduce the man’s observations so drastically and suddenly
also seems flawed. Given his bizarre behaviour in the Segregation Unit only
a short time before the review, it should have alerted staff to the fact that
27
things were not as positive as they seemed. Also, despite the presence of a
mental health professional at the ACCT review, they were not even aware that
The man had not undergone his mental health assessment.
121. I have made a number of recommendations, in conjunction with the clinical
reviewer, which I hope will alert staff to the issues which appear to have
contributed to the man’s death, and I hope the acceptance and
implementation of the recommendations will make a difference for prisoners in
the future.
28
RECOMMENDATIONS
To the Governor and Head of Healthcare:
1. The Governor and Head of Healthcare should ensure that all options are
thoroughly explored by staff before a prisoner is moved from healthcare to the
Segregation Unit, especially if they have failed the algorithm a few hours
earlier.
Recommendation accepted by prison
2. The Governor and Head of Healthcare should ensure that staff carrying out an
ACCT review are adequately trained, and should be fully aware of the
prisoner’s history. In particular, healthcare professionals should be aware of
the importance of their specialist knowledge and responsibilities in that area
(for example, mental health assessments).
Recommendation accepted by prison
3. The Governor and Head of Healthcare should ensure that all staff are told
where defibrillators are situated around the prison, and are able to gain
access to them in an emergency.
Recommendation accepted by prison
4. The Governor and Head of Healthcare should ensure that all qualified first
aiders are issued with appropriate equipment.
Recommendation accepted by prison
5. The Governor and the Head of Healthcare should ensure that medical records
are maintained in line with General Medical Council guidelines.
Recommendation accepted by prison
To the Governor:
6. The Governor should remind staff of the importance of following ACCT
guidelines and of recording all prisoner observations in the ACCT.
Recommendation accepted by prison
7. The Governor should review the system for passing correspondence around
the prison, to ensure that important documents are seen as a matter of
urgency.
Recommendation accepted by prison
To the Head of Healthcare:
8. The Head of Healthcare should ensure that there are failsafe processes in
place for referrals and follow through in a timely fashion.
Recommendation accepted by prison
9. The Head of Healthcare should ensure that clinical records are available to
clinicians or that the clinician has access to the electronic system before
reviewing a prisoner.
29
Recommendation accepted by prison.
30