Individual at Reading

Investigation into the circumstances surrounding the
death of a man at HMYOI Reading
in 7 September 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
March 2007
This is the report into the investigation of the death of a man in September 2005 at
HM Young Offender Institution Reading. He was found hanging in his cell, and had
left a note indicating that he had committed suicide.
I would like to offer this public expression of sympathy and condolences to the man’s
relatives and friends on their loss. A key objective of all my investigations is to
ensure that the bereaved family has the opportunity to raise any concerns and
contribute to my inquiries. The man was adopted as a child and had renewed
contact with his biological father during the year before his death. He had nominated
a friend as his next of kin. One of my Family Liaison Officers contacted the man’s
adoptive parents, his biological father and the friend during the investigation. I know
they have all waited patiently for this report and very much regret the delay in its
completion. I hope it begins to offer answers to their many questions.
The investigation was led by my investigators who were assisted by a colleague. A
clinical review was conducted by a lady from Reading Primary Care Trust. I am very
grateful for their comprehensive and detailed work. The man had contact with staff
from a number of other agencies. All were contacted as part of the investigation and
I am indebted to them for their assistance. I thank the staff at HMYOI Reading and
particularly the governing Governor who acted as the establishment’s liaison officer
with my office.
The man was a troubled 19 year old who, two days before he was found hanging,
had been sentenced to five years imprisonment. He had said that he might self-
harm when sentenced and this increased risk was known to some members of
Reading’s staff. However, after his return from court, he was not placed on any self-
harm monitoring procedures.
My report contains a large number of recommendations, reflecting the seriousness of
the matters raised by this investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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CONTENTS PAGE
Summary
The Investigation Process
Background Information
HMYOI Reading
Key Events
Previous period in custody
From the man’s arrest
The man’s transfer to Reading
4 September
5 September
6 September
Finding the man
Issues
Recommendations
Recommendations from the Clinical Review
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SUMMARY
The man was initially remanded to HMP Highdown in January 2005. Following
sentence for an unrelated matter, he was transferred to HMYOI Feltham where he
remained until being moved to HMYOI Reading on 18 July. There had been a
number of concerns regarding the man’s conduct towards other prisoners following
an incident on a previous period on remand. Consequently, he was always located
in a single cell and showered alone.
On 3 August 2005, the man was placed on self-harm monitoring at Reading after he
had indicated that he might harm himself. He was seen by a psychiatrist for the
purpose of preparing a report for sentencing on 9 August. During this interview the
man said that he would consider suicide if he received a prison sentence. A
psychiatrist assessed the man as not suicidal at that time, but informed healthcare
staff of his increased risk following sentence. The man’s self-harm monitoring was
closed on 13 August.
On 5 September 2005 the man appeared at Kingston Crown Court for sentencing
and received a total of five years. Having learned of the man’s vulnerability to self-
harm in the psychiatric report and pre-sentence report, both his barrister and the
court probation officer expressed their concern to the custody staff. However, staff
did not consider him to be at risk and did not complete an ‘At risk of self-harm’ form
which would have travelled with the man and alerted staff at Reading to any risk.
Upon his return to Reading, he was seen by a nurse who knew him and was aware
of his increased vulnerability following sentence. However, as she did not assess
the man to be at any immediate risk she did not open a self-harm monitoring form.
The man was located back to his cell.
The man spent most of the following day in his cell as the prison was in ‘patrol state’
as officers were attending a training course. He briefly saw a nurse who knew him,
and they spoke about his recent sentence. The man’s demeanour gave her no
cause for concern. He also chatted with a number of fellow prisoners about his
sentence but did not express any worries.
The man did not collect his medication for insomnia that evening. Cell bell records
indicated that he rang his bell on three occasions between 7.49pm and 8.55pm.
None of the officers on duty can recall answering the man’s bell. A number of
prisoners in the vicinity described hearing some shouting either by the man or to him,
but their reports were not consistent.
On 7 September, during the roll count at 6.00am the man was found hanging. The
alarm was raised and staff attended immediately. Resuscitation was not attempted
as it was clear that the man had been dead for some time. He was declared dead at
6.23am. He left a note.
In addition to a long list of recommendations made by the clinical reviewers, I have
made a further ten recommendations of my own.
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THE INVESTIGATION PROCESS
1. The lead investigator conducted a preliminary visit to HMYOI Reading on 10
September 2005 and returned on a number of occasions to interview staff.
During the course of initial enquiries, the investigation team was shown
around the prison and visited the cell where the man died. They reviewed all
the relevant documentation and established a chronology of events.
2. Notices were issued to staff and prisoners telling them of the investigation and
offering them the opportunity to speak with my colleagues. No-one came
forward as a result. My investigators met with representatives of the local
branch of the Prison Officers’ Association (POA) and members of the
Independent Monitoring Board (IMB).
3. Fifteen members of staff, both discipline and healthcare, were interviewed at
Reading. Two officers involved in the events went off on long-term sick
following the death and were eventually interviewed in February 2006
following their return to duties. The nurse who saw the man on his return from
the court left the Prison Service, for unrelated reasons, soon after his death,
but kindly agreed to be seen and interviewed at the prison.
4. Given that the man died within 48 hours of being sentenced, my colleagues
widened the scope of the investigation and contacted all staff with whom he
came into contact during this time. This included escort staff, the senior
probation officer at court, the man’s barrister and Serco staff who managed
the cells at Kingston Crown Court. Scheduled interviews with Serco staff
were terminated at the request of their area manager so that legal advice
could be taken. It is my understanding that Serco conducted their own
investigation and subsequently provided my investigator with statements from
staff. These are annexed.
5. The probation officer, who prepared the man’s pre-sentence report was
interviewed. The author of the psychiatric report, spoke with my investigator
on the telephone. A copy of my report will be made available to the National
Probation Service.
6. The man’s biological father and nominated next of kin were met in person by
the lead investigator and one of my Family Liaison Officers (FLOs). The
man’s adoptive parents were contacted by both two of my (FLOs).
7. The clinical reviewer led a team which undertook a clinical review of the
healthcare provided for the man whilst at HMYOI Reading. The review is
annexed.
8. A draft version of this report was sent to the Prison Service. An action plan
was provided in response. The Prison Service indicated whether they
accepted the recommendations or not. The responses can be found under
the recommendations section of this report and have been reproduced
verbatim.
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9. Neither the biological father nor the nominated next of kin commented on the
draft. However the adoptive parents raised several matters, the majority of
which were dealt with by way of a letter. Paragraph 71 has been added to the
draft report in response to a query made by them.
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HMYOI READING
10. Reading is a remand centre and young offender institution, holding young
adults aged between 18 and 21 years. The certified normal accommodation,
without overcrowding, is 196. The prison has an operational (maximum)
capacity of 289. The accommodation consists of three main wings, a
segregation unit and a separated prisoners unit (SPU) on E wing. There is
also a 20-bed resettlement unit, Kennet House, which forms part of the
resettlement estate for young offenders. C wing houses young adults on
induction on two landings. The third landing is mainly for young adults who
work around the prison. B wing is also mainly for workers while A wing is a
general wing holding both remanded and convicted prisoners.
11. Her Majesty’s Chief Inspector of Prisons conducted an inspection of Reading
in 2004. Ms Owers concluded that Reading was an “improving
establishment”. However, she identified a number of areas where there was
still much to do. These included “delivery of much more equitable provision of
time out of cell and improved and expanded purposeful activity to occupy this
time”. This concern was echoed by members of the Independent Monitoring
Board who spoke to my investigators.
12. There were two apparently self-inflicted deaths at Reading in June and July
2005 which have been investigated by my office. These have yet to proceed
to inquest.
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KEY EVENTS
Previous period in custody
13. The man was remanded into custody for the first time on 26 August 2004
when he was received at HMYOI Feltham. His Cell Sharing Risk Assessment
(CSRA) form indicated that it was his first time in custody and stated ‘history
of fighting (states he has a problem with being on his own), single cell’. He
completed an Initial Custodial Reception Assessment and said that he did not
have a history of self-harm. He was not assessed to be at risk.
14. On 30 August, a security report was raised as a result of an allegation that the
man had made an advance towards another boy in the showers.
Subsequently he was moved to another wing. Following the incident an
instruction appeared in his history record that he was to be showered alone.
There were a number of further security reports that he had been
confrontational with other prisoners.
15. Given the nature of the man’s alleged offence (involving an underage female),
he immediately became subject to Public Protection Procedures. As a result,
monitoring procedures were put into place regarding contact with anyone
under the age of 18 years old. On 1 September 2004 the man signed a
notification regarding contact with those under 18. He was informed that
these were in place due to his impending prosecutions.
16. The man was also told that all incoming and outgoing mail would be vetted
and that he would not be allowed any correspondence with under 18 year
olds, or visits, unless parental consent was obtained. His telephone calls
would be recorded and vetted. He was informed that if he wanted contact
with anyone under 18 he needed to apply.
17. An Assessment, Care in Custody and Teamwork (ACCT) document
(monitoring those at risk from self-harm/suicide) was opened on September
14 as he told staff that he had previously tried to hang himself outside of
prison, and felt he could self-harm at any time. Following indications that he
was going to harm himself the man was admitted to healthcare on 17
September. He did not attempt to harm himself and on 22 September was
discharged back onto the wing. The man remained on an ACCT until 21
October when he was released on conditional bail.
18. The man received a two year conditional discharge for his offence on 4
November 2004. Incorrectly, he was placed on the sex offender register for
two years (the register is not applicable to those who receive a conditional
discharge). The man also became subject to monitoring through Multi Agency
Public Protection Arrangements (MAPPA) as a result of being placed on the
register. On 19 December 2004 he was arrested for an offence of having an
imitation firearm. He was bailed until 11 January 2005.
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The man’s arrest
19. On 10 January 2005 the man was remanded into custody at HMP Highdown
for a further sexual offence involving an underage female. His CSRA stated,
“… was on 2052SH at Feltham. Has attempted to hang himself since the
incident and injury to left wrist.” The man’s wing history sheet indicated that
during his time at Highdown the nature of his offence was discovered, and he
subsequently moved to the segregation unit for his own safety. Following
concerns about his ability to cope on the segregation unit he was seen by the
mental health in-reach team who concluded, “this gentleman does not have a
mental health illness in the true sense but does have personality issues.”
However, he was admitted to the healthcare unit and referred to the
consultant psychiatrist. Prior to being assessed the man moved to Feltham.
20. The man received a four month Detention and Training Order for the offence
of having an imitation firearm and was transferred to Feltham on 20 January
2005 as a sentenced prisoner. His CSRA stated that he should be in a single
cell only. A F2058 (Security file) was raised the following day which stated
that he was not to be placed in a multi-occupancy cell and that he must be
kept away from some named prisoners. An ACCT was opened because of
his history of self-harm. My investigators were unable to establish when this
ACCT document was closed. On 23 January, an entry stated that “he will
only shower on his own due to outstanding charges.” The man again signed
documentation in relation to public protection procedures on 24 January.
21. On 8 February the man was transferred from Feltham and taken to Scotland
for an outstanding case. He remained in HMYOI Castington (in
Northumberland) until 4 April before returning to Feltham. An ACCT was
opened on 3 May after he received a newspaper cutting concerning his
sister’s suicide three years earlier. The ACCT was closed on 11 May, during
which time there had been no incidents of self-harm.
22. The man attended hospital to have a plate and screws removed from an old
injury to his right arm on 3 June. On 9 June, he gained enhanced level of the
Incentives and Earned Privileges (IEP) scheme at Feltham. A few days later,
following a number of behaviour warnings, he was downgraded to ‘standard’
level. His trial took place in June and, having been found guilty, a pre-
sentence report and a psychiatric report were requested for sentencing.
23. On 4 July the man was placed in the segregation unit as there were concerns
about his behaviour towards other prisoners and for his own safety. Feltham
held an emergency MAPPA meeting to discuss how to accommodate him and
he was included in some of these discussions. He was moved back to
ordinary location the following day. However, four days later the man was
again segregated at his own request and he also requested a transfer to
another establishment. HMYOI Reading agreed to take him on the
understanding that he could be located and managed on normal location.
9
The man’s transfer to Reading
24. The man was transferred to Reading on 18 July 2005. His CSRA stated that
he was “received from Feltham, security issues, to be single cell.” A First
Reception Health Screen was completed and the man said that he had
previously tried to hang himself but he did not have any thoughts of harming
himself at that time. His family bereavements were recorded. He was
deemed fit for ordinary location and no further action was planned by medical
staff. Reading inherited two F2052A documents (a prisoner’s history record)
and also opened a new one, the front page of which stated, “to be showered
on his own, phone calls monitor, ring security, single cell.” It indicated that the
man was located to cell C2-20.
25. On 19 July, Reading’s Reception and Induction Records were completed and
the man said he was of no fixed abode. He was asked for details of his next
of kin and he gave the name address and telephone number of a friend. As
part of the induction process he was seen by the chaplain who recorded,
“spoke at length about family bereavement issues – says he will be able to
cope.”
26. The man’s history sheet indicated that he was moved to cell C2-21 on 2
August. The next day an officer wrote in the wing observation book, “Asked to
see Buddy today, after seeing Buddy I spoke to the man who explained
pattern of suicide through out family members and has attempted in Reading
and may attempt in the future.” The officer opened a F2052SH booklet (self-
harm/suicide monitoring procedures, superseded in some prisons by the
ACCT document). A nurse was called to the wing by the officer to complete a
healthcare assessment. She took a family history from the man and recorded
him saying he “shouldn’t be alive because other members of his family were
dead.” The nurse recommended that he be located on normal location, in a
single cell and on a level 1 watch. (There are four levels of monitoring for
those on a 2052SH booklet. However, for those in single cells, only level 1
and 2 are applicable. They are required to be on an intermittent watch at all
times.) It was the policy at Reading for any prisoner on a F2052SH to be
seen daily by a member of healthcare staff, preferably a mental health nurse.
27. The following morning, 4 August, the man was assessed by a General
practitioner at 10.20am. The GP described him “clearly impulsive and labile.
Will need close watching.” He recommended a level 1 watch and said that
the man was requesting a shared cell but was in single accommodation due
to the nature of the charge he was facing. Additionally, he recommended
that: “the man should have time with buddy, refer for bereavement
counselling, and refer for psych opinion (due court report), and needs full risk
assessment by in-reach, amenable to available help.” The GP noted that the
man was a poor sleeper and prescribed 50mg Amtriptyline nocte (at night) to
help him sleep.
28. At 2.45pm the man’s F2052SH Watch Sheet recorded “requested to see
chaplain”. There is no record of whether or not this was acted on by staff. At
3.10 pm, a self-harm injury form (F213SH) was completed after he was found
10
with superficial lacerations to his left wrist caused by cutting with broken
glass. The wounds were cleaned and dressed. Following this incident he
was moved to the care-suite, cell C1-22, for the night.
29. The next day a nurse saw the man and recommended that he be returned to
ordinary location. She observed that he was much more settled. The man
returned to cell C2 –21. Later she again recorded in the IMR (Inmate Medical
Record) that the man, “feels that a lot of his problems is boredom – feels he is
locked up for very long periods at Reading.” The nurse encouraged him to
get involved in all aspects of the prison regime.
30. A psychiatric consultant undertook a psychiatric assessment, including a full
family and social history, that morning. With reference to his forthcoming
sentence the consultant noted that, “the man is uncertain of the sentence” and
that “he denies suicidal thoughts at present although feels suicidal when in
jail.” The consultant wrote the following entry in the F2052SH: “no evidence
mental illness. Long history of self harm but not suicidal intent. In my opinion
the 2052SH should be closed.”
31. During the afternoon the man was taken for a video link interview with a
probation officer. The interview was for the purpose of preparing a Pre-
Sentence Report. The man was not known to the probation officer, but she
had had sight of a number of documents relating to him. In interview with my
investigator, she described him as being “really unrealistic about what was
going to happen [at court].” During the meeting he showed the probation
officer cuts to his arms and told her that he was being monitored.
32. On 6 August, a review of the man’s F2052SH was conducted by an agency
nurse and by an Acting Principal Officer. They noted that the man was
cheerful and that he had no thoughts of self-harm. In response to being
asked about the cuts he made the day before he stated that he “was bored
and he had no one to talk to …” They spoke with him about ways of applying
for activities in the prison. The review concluded that, “although a recent
interview with the psychiatrist suggested this 2052 SH can be closed the
review team agreed to reduce the level and to be observed/ monitored for a
further week. Review 13/8/05.” A corresponding entry in his F2052SH stated,
“2052SH review. Reduced to level 3, see review notes.” A further entry in his
IMR said, “feeing [illegible] and bored in his cell. Cut his wrists – done it may
times before. Does not want to go to education – boring. Would prefer to get
a job – like a cleaner. Encouraged to [illegible] offending [illegible] courses
but says does not like reading. Reviewed from level 1 to level 3. Review in a
week’s time.” Level 3 observations are for those in a shared cell and stipulate
that the prisoner must be watched intermittently when alone in the cell.
Although the watch sheet had “level 3 – single cell” written at the top of the
page the man continued to be monitored intermittently in line with level 1
observations.
33. Later that day he was seen by the same nurse. She described him as very
positive over his future and recorded, “he’s been told ‘good things’ by the
probation team – he may get out soon??” In interview the nurse explained
11
that the man told her that he had been led to believe that he was getting out
soon. She was very shocked by this as she knew that he was facing serious
charges. Furthermore, he said that an outstanding charge in Scotland had
been dropped (this was not the case). The nurse did not want to deflate his
upbeat mood so did not say anything to the contrary. She explained that he
had mentioned that he was very bored in a cell on his own and, because of
this, healthcare staff always tried to take him off the wing for their interviews.
34. There is no entry in the man’s IMR for 7 August. His F2052SH stated that he
was very settled in mood and there were no concerns about him. A duty
governor’s check of the F2052SH said “all correct”. The next day, the duty
governor commented, during a routine check of the documentation, that the
man must be dealt with as a “level 1 as he is in a single cell.” The man spent
25 minutes with another nurse who recorded that he appeared happy in
mood.
35. On 9 August, his F2052SH indicated that he was in high spirits. He told staff
that being on a F2052SH was helpful as it showed that officers cared, and
were concerned about his welfare and well being.
36. During the day the man was seen by a psychiatrist for the purpose of
preparing a psychiatric report for sentencing. In the IMR the psychiatrist
recorded that the man had told him that he had attempted to kill himself nine
times and noted that this was inconsistent with IMR documentation. The
psychiatrist concluded that the man did not appear depressed during
interview, and had no current thoughts of suicide, but had said that he would
think again if he received a prison sentence. The psychiatrist and a nurse
spoke about the man after the interview. In interview the nurse confirmed that
the psychiatrist had explained that, whilst he did not think the man was a risk
at this stage, this could change once he was sentenced.
37. The psychiatrist told my investigator that the man presented as cheerful, polite
and jovial and had said that he had plans for the future. He did not view him
as an imminent risk at that time. However the man had said that he might
harm himself if he got a sentence and the psychiatrist confirmed that he had
shared this information with healthcare.
38. An entry in the man’s F2052SH that day indicated he told an officer that he
did not know why he was in a single cell and that he would much prefer a cell
mate. There are no entries in the IMR on 10 August. His F2052SH recorded
that he had a legal visit via video link for most of the day. Otherwise, he was
described as being in a happy mood.
39. On 11 August the man told medical staff that he had not been given his
medication the day before. This is confirmed by the prescription chart
although there is no record of any follow-up. The F2052SH indicated that he
was in good spirits. The next day, the IMR recorded that there was no
change in his condition. However, the F2052SH stated that he was very
angry after seeing the nurse but no other details are given. Otherwise he was
described as quiet.
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40. A nurse who had seen the man a few times previously described him as being
well and with no concerns on 13 August. At 4.30 pm his F2052SH was
reviewed and closed by a Principal Office, residential unit manager, and a
Health Care Officer. Neither staff member had been present at the man’s
previous review nor written any entries in his F2052SH document. The review
indicated that the man felt positive about his situation and that he had no
thoughts of self–harm. It was recorded that he was having regular contact
with his father and friends and that he felt that he might be released from
custody in early September. The wing observation book recorded that the
review was closed and that the man was “more relaxed”. This is the last entry
regarding the man the wing observation book. There is no record of the
F2052SH being closed in the man’s IMR.
41. In interview the nurse who had seen him a few times previous said she was
on duty that day and was shocked when she discovered that she had not
been called to the review. It was a Saturday and only two healthcare staff
was on duty. The nurse was not aware of why she was not present at the
review. She said that, although it was not unusual to close a 2052SH at
weekends, it was not routine practice.
42. Entries in the IMR for 14, 15 and 16 August all identified the man as stable.
There were no concerns about him self-harming. It may have been the case
that healthcare staff continued to see him because it was not recorded that his
F2052SH had been closed. On 19 August the nurse wrote that, “the man had
seen the bereavement counsellor twice and is able to talk to her freely.” In
addition, she recorded, “F2052SH closure review also states not suicidal or
has any thoughts of at all, has made friends within the prison and is feeling
much more ‘settled’ now, going to exercise and association also.” This is the
last record in the man’s IMR. According to the prescription chart, he did not
have his medication that day. Again, there is no record of a follow-up.
43. On 20 August the nurse wrote in the healthcare centre’s communication book,
“apparently this young man’s F2052SH closed by a PO and someone from
healthcare – on 13th. I was not on that day yes I was sorry – name [removed]
was it you? as me and you on that day, can you make an entry into the IMR
F2052SH closed. But can we be aware that of Psychiatrist who visited him in
the prison 9/08/05 – wrote 9/08/05 – if he gets a sentence to prison he would
think again about killing himself – please can you find out when he is getting
sentenced or next at court – as this young lad single cell and long history dsh.
Due to be sentenced 5th September??”
44. The man saw a worker from the counselling, assessment, referral, advice and
throughcare (CARAT) team for an initial assessment on 26 August. He
discussed his drug and alcohol use, and it was the intention to start a
structured one to one programme the following month. A written statement
from the CARAT worker said that the man gave no indication that he intended
to take his own life, and had spoken about making plans for the future.
13
4 September
45. Another nurse who saw the man previously, saw him at the treatment hatch
when he collected his sleeping medication. In interview, she described feeling
she had a rapport with him. Although she did not see him in a structured,
formal setting, she often chatted with him when he came to collect his
medication. Although she signed the prescription chart indicating that he was
given his medication at tea time (around 4pm), in interview she said she
believed that she had made a mistake and had actually given it to him at
night-time. His prescription had been renewed the day before but had been
written up for collection at teatime rather than at night, as had been the case
previously. The nurse was aware that the man was going to court for
sentencing the next day and she spoke to him about it. She described telling
him that she would be there the next day if he needed to talk. The nurse told
my investigators that she was aware of the psychiatrist’s concerns for the man
following sentence. Both nurses who had seen the man previously confirmed
that they had spoken with each other about his impending court case and its
implications in light of what he had said to the psychiatrist.
5 September
46. One of the nurses, who had seen the man previously was working in
reception in the morning, could not recall whether she saw him prior to him
leaving for court. The man’s case was unusual because he was returning to
Kingston Crown Court for sentencing. (Kingston is not a court usually served
by Reading. The man had been transferred from Feltham which does
accommodate prisoners from Kingston Crown Court.) The private company,
Reliance, who collected and returned him to Reading, were not Reading’s
usual escort service.
47. According to his Prisoner Escort Form (PER), he was handed to the escort
staff at 06.47am. The PER form, which is completed by prison staff,
highlighted the risk categories ‘sex offence’ and ‘suicide/self-harm’. Further
details were given as “(2052 closed, MAPPA) rape, at/perv/just, must return to
Reading, not to go to Feltham or H’Down.” At 08.50am, the escort driver,
wrote “15 min watch”. My investigator spoke to the escort driver who
explained that it was standard procedure to place everyone on a minimum of
a 15 minutes watch. The man arrived at court at 9.50am.
48. When the man went into court at 3.00pm, he was sentenced to five years
imprisonment. For the purpose of sentencing, the court had sight of the Pre-
Sentence Report (PSR) and the psychiatric report. The probation officers
PSR concluded that -
“The man is aware that the Court will be considering a lengthy custodial
sentence today and this is an outcome he is anxious about. He
unrealistically stated that a ‘curfew would do for him’ or a fine. The man
will present as a risk of suicidal thoughts and actions and should be
monitored by the prison staff.”
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49. The psychiatrist, Specialist Registrar in Forensic Psychiatry, concluded his
lengthy Psychiatric Report -
“The man has given contradictory accounts of his history of self harming
and suicide attempts. However, there is evidence of self harming taking
the form of cuts to his forearms, he has a number of depressive
personality traits and has recently suffered the loss of his sister. He has
also made threats of suicide if he were to be given a custodial sentence.
Therefore if he is given a custodial sentence he will require close
monitoring and a considerable amount of input to manage the increased
likelihood of self harm. It is likely that following sentence he may require a
period as an inpatient in the healthcare centre and will require
appointments with the prison in-reach team. He will need support in
dealing with bereavement issues following the loss of his sister in
traumatic circumstances.”
50. These reports do not appear to have been returned to the prison with the
man. The probation officer explained that it was unusual for her not to read
the psychiatric report in advance of the court date. My investigator has had
sight of an email which highlighted her concerns about this. She had
requested that the court probation officer try to seek an adjournment, but it
had been thought that this would not be granted by the judge. Instead she
and the psychiatrist had spoken on the telephone about the man. However,
she did not recall them speaking in detail about the psychiatrists concerns in
relation to the man’s threat to self-harm.
51. The probation officer explained that she understood that the court duty officer
would read the report and pass any information regarding risk to the
necessary staff. The senior probation officer in court stated in interview that
on the basis of what he had read in the probation officers report he
telephoned down to the court cells to relay the concerns about the man to
staff. Serco staff have confirmed this was the case.
52. Following the man’s death, his barrister wrote to Reading to highlight that she
had drawn the attention of court staff to the man’s vulnerability to self-harm.
My investigator spoke with the barrister and she subsequently produced a
statement. She explained that she was familiar with the man having
represented him at his trial, but had not been aware of his self-harming and
suicide attempts prior to learning of them in the court reports. She described
how she had visited him in the cells both before and after sentence. After
sentence she approached the cell staff and explained that she was very
worried about him as reports had mentioned his potential to self-harm. She
asked for the man to be put on suicide watch “for a couple of weeks” as he
had just received a substantial sentence.
53. Serco staff provided statements to my investigator via their solicitors. A
prisoner custody officer stated that the man’s advocate mentioned concerns
to him and said “can you tell your supervisor to keep an eye on him?” The
custody officer said that he passed this information onto his supervisor who is
a Senior Custody Officer. The Senior Custody Officer did not recall being told
15
this. However, she said that she had taken a phone call from the courts
Senior Probation Officer, regarding the man’s self-harm history. She
remembered looking at the PER and seeing that the F2052SH had been
closed which she took “to mean that the prison had therefore assessed him to
be no longer at risk.” She added, “I decided not to increase his watch from
our normal ten minutes to five minutes. I can’t remember if I mentioned that
conversation to any member of my staff.”
54. A prisoner custody officer at the court said that she was aware of the
concerns that had been expressed about the man and that she told the escort
staff to keep a close eye on him. However, he appeared fine and did not give
her any cause for concern.
55. The man’s barrister said that after sentence the man was most concerned
with the Sexual Offences Prevention Order (SOPO) and the terms within it.
He explained that he was being prevented from phoning anyone female, or
his male friend who was 15/16 years old. (The terms of the man’s SOPO
were all related to females under the age of 16 years old. However,
restrictions placed on him in custody were as a result of public protection
restrictions in line with prison policy.) The barrister spoke to court staff and
was told to write to the governor of Reading, which she duly did.
56. My investigator spoke with the two Reliance escort staff who escorted the
man to and from court. The driver recalled the man saying that he thought he
was going to get three years but he seemed fine. He thought that the man
had joked about killing himself on the way to court. However, his co-worker,
who sat with the man in the back of the van, could not recall him saying
anything about suicide. He thought that he had said that he was expecting a
sentence of a couple of months. They did not recall being told anything about
the man by staff at court.
57. An officer was working on the desk in reception when the man returned from
court. He had some knowledge of him from the wing and said that he
appeared to be fine. The man told him he had received five years and had
not been expecting the sentence. He did not say whether he thought it was
going to be more or less.
58. As part of the procedure for those returning from court, each prisoner was
required to see a member of healthcare. One of the nurses who had seen the
man a few times was in reception fulfilling this role. In interview, she
explained that when she saw someone returning from Crown Court, she
would not have any documentation with her regarding the prisoner as the IMR
was kept in healthcare. However, in his case, he was known to her.
59. The nurse was asked in interview to explain the purpose of a member of
healthcare seeing a returning prisoner from court. She explained that she
“would see them to actually establish whether I felt they were at risk because
of the sentence they got.” However, there is no formal assessment to
complete and the only requirement was for prisoners to sign a disclaimer if
they declined to see the doctor. The man signed such a disclaimer.
16
60. One of the nurses who saw the man a few times recalled speaking to him
through the gate of the holding cell in reception, where she said he was sitting
alone. She said she spoke to him for a few minutes and asked him how he
was and “whether he wanted to talk more?” She recalled that he had not
wanted to and that there was nothing in his demeanour to suggest he would
take his own life. She did not directly ask prisoners about feeling suicidal as
she believed this might in some way influence them. She did not write
anything in his IMR about her assessment of the man.
61. The man was one of four sentenced prisoners who returned from court that
evening. From the records, it seems the nurse saw 11 prisoners in total,
which she described as not being a particularly busy evening duty in
reception.
6 September
62. In interview the other nurse who saw the man a few times recalled that she
had seen him in passing, on the landing during the morning of 6 September.
She asked him about court and he said that he could have got eight years so
it had been a good result. She felt that he was fine and was not concerned
about him.
63. Records from the man’s cell bell indicated that he pressed it at 8.44am,
9.50am, 10.09am and 3.39pm. The prison was in ‘patrol state’ that day as
many of the officers were on Control and Restraint training. As a
consequence, only a minimal number of staff were available on the wing so
prisoners would have been locked in their cells for the majority of the day. Of
those patrolling the landings, none was able to recall answering the man’s cell
bell.
64. Between 1.45pm and 3.00pm the man was seen by a prison officer for the
purpose of completing an Initial Classification and Allocation document (a
form completed on all sentenced young offenders for the purpose of
classifying and allocating them to a training establishment). This was the first
time the officer had met him. In interview, the officer said that the man
“seemed to be ok, nothing untowards, he wasn’t agitated, he didn’t seem
depressed, seem like your average normal prisoner.” The man did tell him
that he had been expecting a three year sentence, but the officer had no
concerns about his well being.
65. The man’s prescription chart was not signed for 6 September so it is assumed
that he did not collect his medication that day. My investigators have been
unable to establish why this was the case.
66. The cell bell records for the evening identify the man ringing his bell at
7.49pm, 8.30pm and 8.55pm. My investigators have spoken with staff on duty
and no-one can recall responding to his bell. In a nearby cell, the prisoner
was on an open F2052SH and was being checked regularly. Between
7.30pm and 8.32pm an officer carried out this prisoner’s checks. He was
17
familiar with the man and in interview said that, if a cell bell had gone off in his
vicinity, he would always answer it. However, he was unable to recall whether
or not he answered the man’s cell bell. He explained that cell bells ring all the
time and he would not recall individual ones unless something of significance
occurred. He stated, “it might have been me but I just can’t remember, like I
said it would have jogged my memory if it was significant.”
67. Similarly two other officers signed the F2052SH watch of the other prisoner at
8.52 pm and 9.10 pm respectively. Both officers were on their first night duty
for the week, having had the last four days off. Neither was aware that the
man had been to court and sentenced the day before. One of the officers
could not recall whether he answered the man’s cell bell. The other officer
said that he always checks all the F2052SHs when he first comes on duty, but
did not have reason to speak to the man.
68. An officer who was responsible for the night roll check on C2 and records
indicate that he completed the check at 8.15pm. In interview, he recalled that
the man was sat at his table when he observed him through the cell door
hatch. The officer said that they had a ‘laugh and a joke’, but could not
remember exactly what had been said during the course of the conversation.
69. A number of prisoners were spoken to as part of the investigation. Two
prisoners said that they had spoken to the man on exercise after he had been
sentenced. One of the prisoners said that he told him that he had got five
years and seemed fine about that. The other prisoner who said he knew the
man well saw him in the dinner queue and also felt that he was fine. He said
that the man thought he was going to get eight years. Another prisoner said
that the man was surprised to get five years and told him that he thought he
would have got a shorter sentence had he been in Scotland.
70. Members of the IMB informed my investigators that the chaplain had told
them that, during a group session, one prisoner had spoken about hearing the
man shouting out that he was going to hang himself, and was ringing the bell,
between 9.00pm and 11.00pm. The same prisoner had since moved prison
and was spoken to on the telephone by one of my investigators. He said that
he had heard an officer tell the man “to shut the fuck up” and “ride it out”.
Given that none of the officers are able to recall going to the man’s cell, my
investigators have been unable to verify this. Another prisoner located in the
vicinity said he had heard and seen the man’s cell door being opened at about
10.30 by a number of officers who then entered the cell. My colleagues
tested this out and found that it was not possible to view the cell door from the
cell this prisoner was located in. Another prisoner said that he had heard
someone shouting comments out to the man saying that they were going “to
get him” and that he was there for raping someone. Again, this has not been
verified by staff or fellow prisoners. It has not possible to gain a clear picture
of what happened in response to the man pressing his cell bell that night.
18
Finding the man
71. At approximately 6.10am on 7 September, during the morning roll check one
of the officers who signed the F2052SH watch of the other prisoner looked
through the cell hatch into the man’s cell and saw him hanging from the
ventilation unit. He immediately shouted out and the other officer who signed
the F2052SH watch who was counting another landing ran and joined him at
the cell door. On the way the officer radioed for Oscar 1, the most senior
officer on duty at the time. The duty governor was on the wing as part of his
morning duties, and upon hearing the call for Oscar 1 immediately attended
the cell and unlocked the door with his key.
72. One of the officers supported the man’s legs whilst the second officer climbed
up onto the sink and attempted to remove the shoe lace ligature from around
his neck. Eventually, and with some difficulty, he was able to pass the man’s
head through the loop. Neither officer carried a fish knife which is used to cut
ligatures. Both officers described the man’s body as being stiff and cold and it
was clear that rigor mortis had already set in. They placed him onto the bed.
Paramedics arrived at the prison at 6.19am and the man was declared dead
at 6.23am.
73. The man left the following note in his cell -
“Dear Whom Ever finds me please tell my nominated next of kin and my
father that I cannot handle 5 years for something I have NOT done. TELL
all my friends and family that I loved them very much and I will be waiting
for them over there
Yours sincerely the man”
74. The prison did not contact the man’s nominated next of kin. Instead, the
Governor managed to locate the man’s birth father, by checking through the
man’s telephone records. The father attended the prison the next day. The
details of the man’s adopted parents were found through Scottish Social
Services as there was no record of them in the man’s file.
75. The death in custody contingency plans were complied with by staff. The
care team spoke to all those involved. Two members of staff on duty when he
was found, went off on long-term sick and felt very well supported by the
prison and the care and support team.
19
ISSUES
The increase in risk following sentence
76. The man was a troubled young man with a history of self-harm who had
suffered two sibling suicide bereavements. He had been found guilty of a
number of serious offences and was facing a lengthy custodial sentence. In
spite of telling some staff and fellow prisoners that he was expecting up to
eight years, his remarks to the probation officer suggested that the man
harboured some hope that he might be released from court with a non-
custodial sentence
77. The visiting psychiatrist, interviewed the man for the purpose of a psychiatric
report and he said he might consider suicide if he received a custodial
sentence. This information was relayed by the psychiatrist to healthcare staff
both verbally and in the IMR. Following her discussion with the psychiatrist
one of the nurses wrote an entry in the communications book so all healthcare
staff were aware of the man’s remarks. I am concerned that no other method
was used for communicating such a vital piece of information to a wider
audience. When he went to court, I would have expected that the Prisoner
Escort Record (PER) would have reflected the risk he faced upon sentence.
The Governor should develop a system to ensure that those at risk after
sentence can be identified by court staff, cell staff, discipline and
healthcare staff. This system should be kept under review.
78. In court, both the psychiatrist and the probation officer, reports made
reference to the man’s risk of self-harm. Having learnt about his vulnerability
to self-harm from these reports, the man’s barrister informed the staff
managing the cells at Kingston Crown Court of her concerns. In addition, the
senior probation officer in court contacted the senior custody officer regarding
the man’s self-harm risks. However, staff made their own assessment of him
and did not record any of this information. On the basis of what court staff
was told by both his barrister and the senior probation officer, the ‘At Risk of
Self-Harm’ form should have been completed by the custody officers. The
purpose of this form is to communicate any concerns about the risk of self-
harm that arise when a prisoner is at court. This form should have travelled
back to Reading with the man and alerted reception staff to events at court.
Serco should undertake a local investigation to establish why the ‘A
Risk of Self-Harm’ form was not opened after the man was sentenced.
79. Upon his return to the prison one of the nurses conducted a very brief post-
sentence interview in reception. She was aware of the psychiatrists concerns
but did not directly ask him if he felt suicidal. From his demeanour she
concluded that he was not at risk. I am concerned there may have been an
over-reliance on how the man presented, and that insufficient account was
taken of his previous history. The nurse had not received any suicide or self-
awareness training during her time at Reading.
20
All staff who are engaged in reception screening should have training in
risk assessment, interview skills and suicide awareness, taking into
account the new ACCT procedures, due to be implemented.
80. Prison officers on the man’s wing were not aware that he had received a five
year sentence. I am of the view that a long sentence imposed on a 19 year
old should be regarded as a significant change in circumstances and staff
should be notified of this change. Wing staff were not aware of his increased
risk after sentence. I am concerned that there is no existing method for
healthcare staff to communicate important information to discipline staff. The
clinical reviewers discussed this in detail and I endorse their comments and
recommendations.
Structured systems and processes must be put in place, for
communication both within the healthcare team and the wider prison.
F2052SH procedures
81. The man’s F2052SH was closed on 13 August by two staff members who had
not been involved in any previous reviews. The concerns about his risk
following sentence are not acknowledged in the F2052SH, and it must be
assumed that they were unaware of the psychiatrist’s comments in the IMR.
The clinical review team recommend that once an individual is removed from
a F2052SH/ACCT there should be a system in place for review and follow up.
I strongly endorse this. Reading introduced the ACCT system on 25
September 2006.
A comprehensive post closure support plan should be put in place for
all prisoners at Reading. This should take place at the final review
meeting and prior to the closure of the F2052SH/ACCT booklet. The
Suicide Prevention Co-ordinator (SPC), along with wing staff, should
monitor and follow up each plan.
82. Although the man was in a single cell in Reading, it was recommended that
his level of observations be changed from level 1 to level 3 following a review.
However, for those prisoners in single cells, F2052SH guidance states that
they must be observed at either level 1 or 2 at all times. The error was quickly
rectified and it would appear that his level of observations was not actually
reduced. However, it is worrying that staff responsible for reviews should not
be completely familiar with the self-harm monitoring system.
The Governor should review arrangements for holding, and caring for,
prisoners at risk of suicide or self-harm in single cells.
21
Medication
83. On 19 August the man did not collect his medication. Records indicate that
this was not followed up by medical staff and there are no policy instructions
for medical staff in such circumstances.
84. On 3 September, a repeat prescription for Amitriptyline, an anti-depressant,
was started. Whereas his medication had previously been given at night-time,
the new chart was written up as an evening collection. The arrangements for
collecting medication differ depending on the time given. An evening
prescription would have been collected from the medication treatment hatch
by the prisoner during his time out to collect the evening meal. Those on
night medication are unlocked individually by staff and escorted to the
treatment hatch before returning to their cell.
85. The man did not have his medication on 6 September. It is unknown whether
he intentionally did not collect it at teatime, or whether he had not become
accustomed to collecting it at that time, if indeed this is what happened the
preceding days.
When a prisoner does not attend for their medication this should be
followed up by Health Care staff. The reason for declining medication
and/or alternative arrangements should be recorded in the clinical
record.
Healthcare staff must record in the Clinical Record the reason for
altering the requirements of a prescription.
Cut-down scissors or fish-knife
86. Neither of the two officers who found him carried any means by which to cut
through a ligature. In the absence of having any quick way of removing it the
officer struggled to release the ligature from around his neck. Tragically the
man was already dead and there was nothing that could have been done to
save him. However, this is not always the case, and any hindrance could
have lost valuable seconds.
87. It would be better and safer for all staff working with prisoners to be issued
with a pair of cut-down scissors, or a fish-knife, which are specifically
designed for the purpose of cutting ligatures. I welcome the fact that the
Prison Service is shortly to issue a mandatory instruction requiring staff to
carry such equipment and therefore make no further recommendation.
History booklets
88. HMP Reading inherited two history booklets on the man from Feltham and
also opened a new one. However, the Feltham ones remained in circulation
and so three booklets were completed at different times and no consequential
account was found in one document. There are only a scant number of
entries during his time at Reading..
22
The Governor should remind staff of the need to ensure that prisoner
records are updated as appropriate with relevant information.
The management of the man
89. Due to concerns about the man’s behaviour in custody, he had to be placed in
a single cell, had limited contact with other prisoners and frequently
complained about being bored. In previous establishments he had to be
segregated so Reading did well to locate him on normal location during his
time there. However, during his time at Feltham it is evident that there were
regular discussions about how best to manage him and work with him through
his problems, including how to cope with the lack of activity. From his
records, this work appears to have been undertaken by his personal officers
and probation staff. However, whilst at Reading there is no evidence that any
‘extra’ work was undertaken, and there is only one entry in his public
protection action log which related to the day he came to Reading. At the
time of his death Reading did not have a personal officer scheme and I
believe that he may have missed out as a result. I understand that the
Governor has now reintroduced a personal officer scheme. I strongly
commend this and judge that any recommendation of my own would now be
otiose.
Contacting the next of kin
90. In Reading’s Reception and Induction Record the man named somebody
other than his biological father as his next of kin. During the course of this
investigation, my investigator met the man’s nominated next of kin who said
that he had not been contacted by the prison following the man’s death. The
Governor told my investigator that telephone contact between the nominated
next of kin and the man had been barred in line with a police investigation.
She added that the relationship between the two was not clear and so she
had contacted the man’s father. However, prison records indicated that the
man last telephoned the nominated next of kin on 30 August 2005.
91. Whilst the Governor was trying to do the right thing, the wishes of the man
were ignored. Given a prisoner’s utter dependence upon the authorities for
most aspects of their lives, this is one area where individuals are able to
express their own wishes and these should be respected unless there are
overwhelming reasons to the contrary.
The NOMS Safer Custody Group should review current guidance to
assess whether there are any circumstances when nominated next of
kin should not be approached following a death in custody.
Clinical Review
92. Reading Primary Care Trust undertook a clinical review of the healthcare
provided to the man during his time at HMYOI Reading. The review has
highlighted a number of shortcomings and makes a number of far reaching
23
recommendations which will need to be considered jointly by Reading PCT,
Reading’s Healthcare Manager and the Governor.
93. The clinical review team believe that the decision not to open a F2052SH on
the man’s return from court, the lack of training in suicide awareness and lack
of effective communication systems were significant factors in him taking his
own life.
94. The recommendations made by the clinical review team echo the issues
identified in my report and I endorse all their recommendations. I am aware
that Reading PCT have developed an action plan in the light of these
recommendations.
24
RECOMMENDATIONS
1. The Governor should develop a system to ensure that those at risk after
sentence can be identified by court staff, cell staff, discipline and
healthcare staff. This system should be kept under review.
Accepted A system for communication to Reading Prison by Court/ Cell staff
is in operation. There is a proforma with instructions to contact a Healthcare
pager for immediate response at all times. This is in addition to the Prisoner
Escort Record (PER) and suicide/self-harm warning form.
In Reception, the Inmate Medical Record (IMR) is available to all those
returning from court and first night keep safe arrangements are used until full
assessment next day by Healthcare and Induction staff.
In addition local system has been developed to identify those sentenced at
Court and on transfer.
2. Serco should undertake a local investigation to establish why the ‘A
Risk of Self-Harm’ form was not opened after the man was sentenced.
Accepted. An internal investigation was conducted by the Deputy
Investigations Officer Serco in November 2005. He made no formal
recommendations but noted from the Kingston Crown Court officer’s
statements that the man had arrived from HMYOI Reading and that a 2050SH
warning had been closed by the prison. He displayed no signs or warnings at
court of any intention to self-harm. That verbal information was given to an
officer by a member of the man’s legal team that he had previously tried to
self-harm and that a request is made to the supervisor to keep an eye on him.
The SCO at the court took note of all the information and had spoken to the
man, he gave her no concerns over his behaviour and the SCO did not
consider it appropriate to open a Suicide/Self-harm warning form. The SCO
did in the knowledge of this information inform staff to keep an eye on the
man.
3. All staff who are engaged in reception screening should have training in
risk assessment, interview skills and suicide awareness, taking into
account the new ACCT procedures, due to be implemented.
Accepted. ACCT was implemented in September 2006. Training was given
prior to implementation for all staff involved in the process. Enhanced training
was given in line with HMPS policy for Healthcare staff and key individuals
within Reading.
In addition, the Gruben Health screen is being used to assist in identification
of prisoners who may require extra support whilst in custody
4. Structured systems and processes must be put in place, for
communication both within the healthcare team and the wider prison
Accepted. Reading PCT Communication protocol and HMPS Communication
strategy detail the formal principles for communication. Within Reading,
Healthcare staff attends the morning briefings, Safer Custody reviews and a
25
manager attends the daily meeting. There is a weekly High dependency
meeting attended by all disciplines to ensure effective communication and
management of difficult cases
5. A comprehensive post closure support plan should be put in place for
all prisoners at Reading. This should take place at the final review
meeting and prior to the closure of the F2052SH/ACCT booklet. The
Suicide Prevention Co-ordinator (SPC), along with wing staff, should
monitor and follow up each plan.
Accepted. There is a dedicated Safer Custody team who liaise closely with
Healthcare and discipline staff. When an ACCT document is closed, a post
closure interview is arranged in line with National Policy.
The Safer Custody Manager is responsible for monitoring documentation
6. The Governor should review arrangements for holding, and caring for,
prisoners at risk of suicide and self-harm in single cells.
Accepted. The ACCT document facilitates multi-discipline involvement and
ownership of care for those young prisoners at risk of suicide and self-harm.
Those also risk assessed as single cell are reviewed when there is a change
in circumstances. If there is a benefit in multi-share occupancy indicated by
the ACCT process, a review of cell sharing is actioned.
7. When a prisoner does not attend for their medication this should be
followed up by Health Care staff. The reason for declining medication
and/or alternative arrangements should be recorded in the clinical
record.
Accepted. Healthcare staff introduced a system, to explore, with individuals,
their reasons for declining medication. This is recorded in the Inmate Medical
Record (IMR) and non medical-in-confidence information is disclosed to
discipline staff where necessary to keep the individual safe.
8. Health care staff must record in the Clinical Record the reason for
altering the requirements of a prescription.
Accepted. This relates to any specific time or change to time of medication
requirement of the prescription that might alter the effectiveness, at night, for
example. Detailed records are now in existence to remedy this possibility.
9. The Governor should remind staff of the need to ensure that prisoner
records are updated as appropriate with relevant information.
Accepted. The personal officer scheme has been re-established at Reading
to ensure better quality information is recorded in History sheets for individual
prisoners
26
10. The NOMS Safer Custody Group should review current guidance to
assess whether there are any circumstances when nominated next of
kin should not be approached following a death in custody.
Accepted. This will be considered in the wider review of PSO 2710 Follow up
to deaths in custody
27
RECOMMENDATIONS FROM THE CLINICAL REVIEW
11. Clear policy and guidance should be developed which clearly states the
roles and responsibilities of those individuals within the health care
team, particularly with regard to:
o The lead nurse on duty
o The health care representative of the review team for F2052SH
o Daily communication and updates on individuals causing
concern.
Accepted. There is an Action Plan in conjunction with Reading PCT to
address recommendations from Clinical Reviews already in place.
The Role of the Lead nurse has been published.
RMN attends Safer Custody meetings and the Role of a Healthcare
representative on the ACCT review team has been formalised.
There is a morning handover book for outstanding issues and attendance of
Healthcare at the daily Prison staff briefing. A weekly High Dependency
meeting operates for difficult case management.
12. Consideration should also be given to developing a key nurse role for
those prisoners who are considered to be at risk.
Accepted. Within the local Safer Custody team there is an individual identified
as lead in each case. This will be developed within the Healthcare staff roles
and responsibilities for those considered at risk.
13. All staff should undertake annual mandatory training in suicide
awareness and risk assessment and a record of this should be
monitored by the head of health care.
Partially accepted. All Healthcare staff has undergone training prior to
implementation of ACCT in September 2006 and are competent in completion
of Gruben Health screening where appropriate. National Policy no longer has
mandatory training. All training is monitored by Head of Healthcare.
14. All staff who are engaged in reception screening should have training in
risk assessment, interview skills and suicide awareness and be
competent to do so.
Partially accepted. All Healthcare staff has undertaken training in line with
ACCT implementation to better assess risk and improve the inquiry process to
better identify those potentially at risk, which includes the Gruben Health
screening tool
15. IMRs should be accessible to staff on reception for prisoners returning
from sentencing.
Accepted. Written Operating Instructions are in place to ensure IMR’s are
accessible to staff on reception for prisoners returning from court. Entries are
monitored by Head of Healthcare.
28
16. All staff who are engaged in reception screening should have training in
risk assessment, interview skills and suicide awareness.
This is the same as number 14.
17. There is a review of current systems within the health care team to
ensure that there are robust processes in place for the:
o Instigation
o Removal
o Follow up of individuals on F2052SH.
Accepted. F2052SH has now been replaced by the ACCT document. Robust
processes exist with the local Safer Custody team in ensuring reviews are
conducted by individuals who have detailed knowledge of the individual.
Rationale for removal from ACCT is detailed and cases followed up with a
care plan.
18. Structured systems and processes should be put in place for
communication both within the healthcare team and between the team
and the wider prison staff.
This is the same as number 4
19. The current communication process should be reviewed, identifying
areas of risk and developing a more consistent pathway approach
between individuals and teams providing health care.
Accepted. A review of relevant meetings has taken place to ensure improved
communication and appropriate attendance at relevant meetings by all
involved in the welfare of a young prisoner.
20. The IMR should be regarded as the main record and all information must
be recorded on the IMR, e.g. open and closure of F2052SHs.
Accepted. Comprehensive information is now recorded on the IMR which
included rationale regarding opening and closure of ACCT documents which
replaced the F2052SH
21. All relevant communications and interventions should be written in the
relevant record/s and signed and the name should also be printed under
the signature.
Accepted. All relevant communications and interventions are recorded in
detail and names are printed under the signature to ensure no doubt exists as
to the author.
22. Record keeping must be improved in line with NMC guidelines and
should form part of regular supervision of staff.
29
Accepted. All staff has a copy of the NMC guidelines for record keeping and
this forms part of the regular supervision of staff.
23. Training related to record keeping and records management should be
provided for all staff
No response given.
24. A system should be established which:
o will alert staff to potential risks, and
o will record changes in circumstances.
Accepted. There are a number of systems that have developed to ensure
changes in circumstances are communicated and recorded.
These include:
Safer Custody meeting
Multi-discipline team meetings
Daily briefings
Morning handover
High Dependency meeting
Personal Officer scheme
More consistent use of the IMR
25. The initial reception screening should be reviewed in line with ACCT.
Accepted. ACCT was implemented in September 2006. All documentation
relates to the revised system.
26. A system to ensure follow up and compliance with healthcare should be
developed.
Accepted. Referral forms, which are audited, have been introduced and all
non-attendance for appointments and medication is followed up
27. A records audit must be undertaken at baseline and reviewed in 6
months.
Accepted. This will be completed.
28. There should be a system in place to ensure that nominated staff who
are involved in closure of F2052SH are fully informed of factors relating
to that prisoner in order to make an informed decision.
Accepted. F2052SH has now been replaced by the ACCT document. Robust
processes exist with the local Safer Custody team in ensuring reviews are
conducted by individuals who have detailed knowledge of the individual.
Rationale for removal from ACCT is detailed and cases followed up with a
care plan.
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29. Closure of F2052SH should be communicated effectively to all team
members both in written and oral form and a follow up programme
developed in line with an agreed ‘step down’ approach.
Accepted. The implementation of ACCT ensures this system operates
effectively.
30. To implement a system to ensure that medical follow-ups at the required
intervals are achieved with reasons for non-attendance made in the IMR.
Accepted. Referral forms, which are audited, have been introduced and all
non-attendance for appointments and medication is followed up.
31. Medication charts should be reviewed on a regular basis by a senior
member of nursing staff and non-compliance monitored.
Accepted. This exists within the published Role of the Lead nurse, supported
by the prison pharmacist.
32. All team members should have a clear understanding of their roles and
responsibilities.
Accepted. These are drafted with further consultation planned on an away
day involving Team Leaders. This will be published following this.
33. Regular clinical supervision should be available to all staff and
arrangements for this and ongoing management support should be in
place.
Accepted. Supervision and Management support are under development for
all Healthcare staff
34. There should be regular interdisciplinary team meetings where
individual care plans are discussed.
Accepted. There are a number of meetings involving all disciplines that have
developed to ensure individual care plans are discussed
These include:
Safer Custody meeting
Multi-discipline team meetings
Daily briefings
Morning handover
High Dependency meeting
35. Wherever possible, there is an integrated approach across health and
prison staff in the development and implementation of policies.
Accepted. Reading PCT have reviewed their integrated policy documents to
reflect both Healthcare and Prison guidance and policy.
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All documents have been and are signed off at The Prison Partnership Board
meeting, held quarterly. In addition the Quality Forum ensures that
improvements are monitored.
36. Efforts should be made to employ staff within the team rather than be
reliant upon agency staff.
Accepted. Posts are advertised as they arise and Agency staff are kept to a
minimum.
37. There should be regular team meetings to discuss clinical care and
significant events.
Accepted. There is a daily meeting to discuss clinical care and a weekly
meeting in which significant events are discussed.
38. Key events and information that affect a prisoners’ behaviour or attitude
should be communicated as a matter of urgency. This should be in
written as well as oral form and should be recorded in the IMR.
Accepted. There are a number of meetings involving all disciplines that have
developed to ensure individual care plans are discussed along with any
changes in behaviour that needs to be communicated
These include:
Safer Custody meeting
Multi-discipline team meetings
Daily briefings
Morning handover
High Dependency meeting
Consistency with IMR recording
Personal Officer scheme
Mental Health referral system
39. There should be urgent consideration of the early implementation of an
integrated and comprehensive IT system to replace hand written records
to the standard described above.
Not accepted. Until this is a National initiative with other prisons and the NHS
involved, any information would only be relevant within Reading Young
Offender Institution and not transferable to another establishment.
40. Urgent consideration is giving to the range of skills and resources
available to support the particular needs of this group of young men.
Accepted. A review of Mental Health services has been undertaken for
Reading YOI. This will look at utilising existing skills and potentially
introducing new resources for gaps in service provision for the young men at
Reading. This will be discussed at The Partnership Board meeting in
November 2006.
New resources are subject to the financial constraints of the NHS.
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